Beruflich Dokumente
Kultur Dokumente
Table of Contents
What Is a TIP?
Editorial Advisory Board
Consensus Panel
Foreword
Executive Summary and Recommendations
Summary and Recommendations
Appendix A Bibliography
Appendix B Information and Training Resources
General Brief Therapy
Cognitive-Behavioral Therapy
Strategic/Interactional Therapies
Humanistic and Existential Therapies
Psychodynamic Therapy
Family Therapy
Group Therapy
Appendix C Glossary
Appendix D Health Promotion Workbook
Part 1: Summary of Health Habits
Figures
1-1 Substance Abuse Severity and Level of Care
1-2 Goal of Brief Interventions According to Setting
2-1 The Stages of Change
2-2 Sample Objectives
2-3 American Society of Addiction Medicine (ASAM) Patient Placement
Criteria
2-4 FRAMES
2-5 Scripts for Brief Intervention
2-6 Screening for Brief Interventions for Alcoholism
2-7 Client Feedback and Plan of Action
2-8 Talking About Change at Different Stages
2-9 Steps in Active Listening
2-10 Professionals Outside of Substance Abuse Treatment Who Can
Administer Brief Interventions
3-1 Criteria for Longer Term Treatment
3-2 Selected Criteria for Providing Brief Therapy
What Is a TIP?
Treatment Improvement Protocols (TIPs) are best practice guidelines
for the treatment of substance abuse disorders, provided as a service of the
Substance Abuse and Mental Health Services Administration's Center for
Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific
Analysis and Synthesis draws on the experience and knowledge of clinical,
research, and administrative experts to produce the TIPs, which are
distributed to a growing number of facilities and individuals across the
country.
The audience for the TIPs is expanding beyond public and private
substance abuse treatment facilities as alcoholism and other substance abuse
disorders are increasingly recognized as major problems.
The TIPs Editorial Advisory Board, a distinguished group of substance
abuse experts and professionals in such related fields as primary care, mental
health, and social services, works with the State Alcohol and Other Drug
Abuse Directors to generate topics for the TIPs based on the field's current
needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal
agencies and national organizations to a Resource Panel that recommends
specific areas of focus as well as resources that should be considered in
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therapy. Appendixes are also included that provide resources for further
information and training, a glossary of terms used in the TIP, and a sample
workbook for use in brief interventions.
The goal of this TIP is to make readers aware of the research, results,
and promise of brief interventions and brief therapies in the hope that they
will be used more widely in clinical practice and treatment programs across
the United States.
Other TIPs may be ordered by contacting SAMHSA's National
Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or
(301) 468-2600; TDD (for hearing impaired), (800) 487-4889
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Rockville, Maryland
Linda S. Foley, M.A.
Former Director
Project for Addiction Counselor Training
National Association of State Alcohol and Drug Abuse
Directors
Washington, D.C.
Wayde A. Glover, M.I.S., N.C.A.C. II
Director
Commonwealth Addictions Consultants and Trainers
Richmond, Virginia
Pedro J. Greer, M.D.
Assistant Dean for Homeless Education
University of Miami School of Medicine
Miami, Florida
Thomas W. Hester, M.D.
Former State Director
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Consensus Panel
Chair
Kristen Lawton Barry, Ph.D.
Associate Research Scientist
Alcohol Research Center
University of Michigan
Ann Arbor, Michigan
Workgroup Leaders
Christopher W. Dunn, Ph.D., M.A.C., C.D.C.
Psychiatry and Behavioral Science
University of Washington
Seattle, Washington
Jerry P. Flanzer, D.S.W., L.C.S.W., C.A.C.
Director
Recovery and Family Treatment, Inc.
Alexandria, Virginia
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Foreword
The
Treatment
Improvement
Protocol
(TIP)
series
fulfills
and
Mental
Health
Services
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Director
Center for Substance Abuse Treatment
Substance Abuse
Administration
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and
Mental
Health
Services
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and policymakers have increasingly focused on them as tools to fill the gap
between primary prevention efforts and more intensive treatment for
persons with serious substance abuse disorders. However, studies have
shown that brief interventions are effective for a range of problems, and the
Consensus Panel believes that their selective use can greatly improve
substance abuse treatment by making them available to a greater number of
people and by tailoring the level of treatment to the level of client need.
Brief interventions can be used as a method of providing more
immediate attention to clients on waiting lists for specialized programs, as an
initial treatment for nondependent at-risk and hazardous substance users,
and as adjuncts to more extensive treatment for substance-dependent
persons.
Brief therapies can be used to effect significant changes in clients'
behaviors and their understanding of them. The term "brief therapy" covers
several treatment approaches derived from a number of theoretical schools,
and this TIP considers many of them. The types of therapy presented in these
chapters have been selected for a variety of reasons, but by no means do they
represent a comprehensive list of therapeutic approaches currently in
practice. Some of these approaches (e.g., cognitive-behavioral therapy) are
supported by extensive research; others (e.g., existential therapy) have not
been, and perhaps cannot be, tested in as rigorous a manner.
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Brief Therapies
Brief therapy is a systematic, focused process that relies on assessment,
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requirements. (2)
Brief therapy for substance abuse treatment is a valuable
approach, but it should not be considered a standard of care
for all populations. (1) The Consensus Panel hopes that brief
therapy will be adequately investigated in each case before
managed care companies and third-party payors decide it is
the only modality for which they will pay.
Brief interventions and brief therapies are well suited for clients
who may not be willing or able to expend the significant
personal and financial resources necessary to complete more
intensive, longer term treatments. (2)
Both research and clinical expertise indicate that individuals
who are functioning in society but have patterns of excessive
or abusive substance use are unlikely to respond positively to
some forms of traditional treatment, but some of the briefer
approaches to intervention and therapy can be extremely
useful clinical tools in their treatment. (1)
When to use brief therapy
Determining when to use a particular type of brief therapy is an
important consideration for counselors and therapists. The Panel
recommends that client needs and the suitability of brief therapy be
evaluated on a case-by-case basis. (2) Some criteria for considering the
appropriateness of brief therapy for clients include
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to the clinician, all forms of brief therapy share some common characteristics
(2):
They are either problem focused or solution focusedthey
target the symptom, not its causes.
> They clearly define goals related to a specific change or
behavior.
They should be understandable to both client and clinician.
They should produce immediate results.
They can be easily influenced by the personality and counseling
style of the therapist.
They rely on rapid establishment of a strong working
relationship between client and therapist.
The therapeutic style is highly active, empathic, and sometimes
directive.
Responsibility for change is placed clearly on the client.
Early in the process, the focus is to help the client enhance his
self-efficacy and understand that change is possible.
Termination is discussed from the beginning.
Outcomes are measurable.
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Therapist characteristics
Therapists will benefit from a firm grounding in theory and a broad
technical knowledge of the many different approaches to brief therapy that
are available. (2) When appropriate, elements of different brief therapies may
be combined to provide successful outcomes. However, it is important to
remember that the effectiveness of highly defined interventions (e.g.,
workbook-driven interventions) used in some behavioral therapies depends
on administration of the entire regimen.
The therapist must use caution in combining and mingling
certain techniques and must be sensitive to the cultural
context within which therapies are integrated. (2)
Therapists should be sufficiently trained in the therapies they
are using and should not rely solely on a manual such as this
to learn those therapies. (2)
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Cognitive-Behavioral Therapy
CBT represents the integration of principles derived from behavioral
theory, cognitive social learning theory, and cognitive therapy, and it provides
the basis for a more inclusive and comprehensive approach to treating
substance abuse disorders.
CBT can be used by properly licensed and trained mental health
practitioners even if they have limited experience with this type of therapy
either as a cost-effective primary approach or in conjunction with other
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therapies or a 12-Step program. CBT can be also used early in and throughout
the treatment process whenever the therapist feels it is important to examine
a client's inaccurate or unproductive thinking that could lead to risky or
negative behaviors. (2)
CBT is generally not appropriate for certain clients, namely, those
Who have psychotic or bipolar disorders and are not stabilized
on medication
Who have no stable living arrangements
Who are not medically stable (as assessed by a pretreatment
physical examination) (2)
Cognitive-behavioral techniques
The cognitive-behavioral model assumes that substance abusers are
deficient in coping skills, choose not to use those they have, or are inhibited
from doing so. It also assumes that over the course of time, substance abusers
develop a particular set of effect expectancies based on their observations of
peers and significant others abusing substances to try to cope with difficult
situations, as well as through their own experiences of the positive effects of
substances.
CBT is generally effective because it helps clients recognize the
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Strategic/Interactional Therapies
Strategic/interactional therapies attempt to identify the client's
strengths and actively create personal and environmental situations in which
success can be achieved. The primary strength of strategic/interactional
approaches is that they shift the focus from the client's weaknesses to his
strengths.
The strategic/interactional model has been widely used and
successfully tested on persons with serious and persistent mental illnesses.
(1) Although the research to date on these therapies (using nonexperimental
designs) has not focused on substance abuse disorders, the use of these
therapies in treating substance abuse disorders is growing.
The Consensus Panel believes that these therapeutic approaches are
potentially useful for clients with substance abuse disorders and should be
introduced to offer new knowledge and techniques for treatment providers to
consider. (2)
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and a focus on the client rather than the symptom. Humanistic and existential
approaches share a belief that people have the capacity for self-awareness
and choice. However, the two schools come to this belief through different
theories.
Humanistic and existential therapeutic approaches may be particularly
appropriate for short-term substance abuse treatment because they tend to
facilitate therapeutic rapport, increase self-awareness, focus on potential
inner resources, and establish the client as the person responsible for
recovery. Thus, clients may be more likely to see beyond the limitations of
short-term treatment and envision recovery as a lifelong process of working
to reach their full potential. (2)
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Psychodynamic Therapies
Psychodynamic therapy focuses on unconscious processes as they are
manifested in the client's present behavior. The goals of psychodynamic
therapy are client self-awareness and understanding of the past's influence
on present behavior. In its brief form, a psychodynamic approach enables the
client to examine unresolved conflicts and symptoms that arise from past
dysfunctional relationships and manifest themselves in the need and/or
desire to abuse substances.
Several of the brief forms of psychodynamic therapy are less
appropriate for use with persons with substance abuse disorders, partly
because their altered perceptions make it difficult to achieve insight and
problem resolution. However, many psychodynamic therapists use forms of
brief psychodynamic therapy with substance-abusing clients in conjunction
with traditional substance abuse treatment programs or as the sole therapy
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Family Therapy
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Definitions of "family"
Family therapy can involve a network that extends beyond the
immediate family, involves only a few members of the family system, or even
deals with several families at once. (2) The definition of family" varies in
different cultures and situations and should be defined by the client.
Therapists can "create" a family by drawing on the client's network of
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significant contacts. (2) A more important question than whether the client is
living with a family is, "Can the client's problem be seen as having a relational
(involving two or more people) component?"
Group Therapy
Group psychotherapy is one of the most common modalities for
treatment of substance abuse disorders. Group therapy is defined as a
meeting of two or more people for a common therapeutic purpose or to
achieve a common goal. It differs from family therapy in that the therapist
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therapy is implemented.
Client preparation is particularly important in any time-limited group
experience. Clients should be thoroughly assessed before their entry into a
group for therapy. (2) Group participants should be given a thorough
explanation of group expectations.
The preferred timeline for time-limited group therapy is not more than
2 sessions per week (except in the residential settings), with as few as 6
sessions in all, or as many as 12, depending on the purpose and goals of the
group.
Sessions are typically IV2 to 2 hours in length. Residential programs
usually have more frequent sessions.
Group process therapy is most effective if participants have had time to
find their roles in a group, to "act" these roles, and to learn from them. The
group needs time to define its identity, develop cohesion, and become a safe
environment in which there is enough trust for participants to reveal
themselves. (2)
Conclusion
The brief interventions and therapies described in this TIP are intended
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1
Introduction to Brief Interventions and Therapies
The use of brief intervention and brief therapy techniques has become
an increasingly important part of the continuum of care in the treatment of
substance abuse problems. With the health care system changing to a
managed model of care and with changes in reimbursement policies for
substance abuse treatment, these short, problem-specific approaches can be
valuable in the treatment of substance abuse problems. They provide the
opportunity for clinicians to increase positive outcomes by using these
modalities independently as stand-alone interventions or treatments and as
additions to other forms of substance abuse and mental health treatment.
They can be used in a variety of settings including opportunistic settings (e.g.,
primary care, home health care) and specialized substance abuse treatment
settings (inpatient and outpatient).
Used for a variety of substance abuse problems from at-risk use to
dependence, brief interventions can help clients reduce or stop abuse, act as a
first step in the treatment process to determine if clients can stop or reduce
on their own, and act as a method to change specific behaviors before or
during treatment. For example, there are some issues associated with
treatment compliance that benefit from a brief, systematic, well-planned
intervention such as attending group sessions or doing homework. In other
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(EAPs), programs for people cited for driving while intoxicated (DWI), and
urine testing programs, as well as in physicians' offices and other health
screening efforts (Miller, 1993). Despite appeals from such distinguished
bodies as the National Academy of Sciences in the United States and the
National Academy of Physicians and Surgeons in the United Kingdom,
widespread adoption of brief interventions by medical practitioners or
treatment providers has not yet occurred (Drummond, 1997; Institute of
Medicine [IOM], 1990).
Figure 1-1
Brief interventions in traditional settings usually involve a more indepth assessment of substance abuse patterns and related problems. The
characterizations of hazardous, harmful, or dependent use as they relate to
alcohol consumption patterns (Edwards et al., were used to distinguish the
targets of brief intervention in a World Health Organization (WHO) study
(Babor and Grant, 1991). Hazardous drinking refers to a level of alcohol
consumption or pattern of drinking that, should it persist, is likely to result in
harm to the drinker. Harmful drinking is defined as alcohol use that has
already resulted in adverse mental or physical effects. Dependent use refers
to drinking that has resulted in physical, psychological, or social
consequences and has been the focus of major diagnostic tools, such as the
Diagnostic and Statistical Manual, 4th Edition (American Psychiatric
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Figure 1-2
Goal of Brief Interventions According to Setting
Setting
Opportunistic setting
Purpose
Facilitate referrals for additional specialized
treatment (e.g., a nurse identifying substanceabusing clients through screening and
advising them to seek further assessment or
treatment)
Affect substance abuse directly by recommending
a reduction in hazardous or at-risk
consumption patterns (e.g., a primary care
physician advising hazardous or at-risk
drinkers to cut down, National Alcohol
Screening Day) or establishing a plan for
abstinence
Neutral environments
(e.g., individuals
responding to
media
advertisements)
Substance abuse
treatment
programs
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recognition or awareness of the problem, even if he has yet to accept it. The
therapy itself is often client driven; the client identifies the problems, and the
clinician uses the client's strengths to build solutions. The choice of a brief
therapy for a particular individual should be based on a comprehensive
assessment rather than a cursory screening to identify potentially hazardous
drinking or substance-abusing patterns (IOM, 1990). In some cases, brief
therapy may also be used if resources for more extensive therapy are not
available or if standard treatment is inaccessible or unavailable (e.g., remote
communities, rural areas). Brief therapies often target a substance-abusing
population with more severe problems than those for whom brief
interventions are sufficient. Brief therapies can be useful for special
populations if the therapist understands that some client issues may be
developmental or physiological in nature (see TIP 26, Substance Abuse Among
Older Adults, and TIP 32, Treatment of Adolescents With Substance Use
Disorders [CSAT, 1998b, 1999b]).
Although brief therapies are typically shorter than traditional versions
of therapy, these therapies generally require at least six sessions and are
more intensive and longer than brief interventions. Brief therapy, however, is
not simply a shorter version of some form of psychotherapy. Rather, it is the
focused application of therapeutic techniques specifically targeted to a
symptom or behavior and oriented toward a limited length of treatment.
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completed.
As assessments became more comprehensive, treatment also began to
address the effects of substance abuse patterns on multiple systems,
including physical and mental health, social and personal functioning, legal
entanglements, and economic stability. In recent years, this biopsychosocial
approach to the treatment of substance abuse disorders has stimulated more
cross-disciplinary cooperation. It has also prompted more attempts to match
client needs to the most appropriate and expeditious intensity of care and
treatment modality. Consideration is now given to differences not only in the
severity and types of problems identified but also to the cultural or
environmental context in which the problems are encountered, the types of
substances abused, and differences in gender, age, education, and social
stability. Determining a client's appropriateness for treatment is one of the 46
global criteria for competency of certified alcohol and drug abuse counselors
(Herdman, 1997). Indeed, client assessment and treatment matching and
referral has become a specialty area in itself that avoids the hazards of
random treatment entry.
In order to test the efficacy of current treatment-matching knowledge,
the National Institute on Alcohol Abuse and Alcoholism (NIAAA) initiated
Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity),
which assessed the benefits of matching alcohol-dependent clients (using 10
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few or minor problems, they are not likely to seek help in the specialized
treatment system. Instead, the estimated 20 percent of the adult population
who drink or use heavily or in inappropriate ways (Higgins-Biddle et al.,
1997) are those most likely to come to the attention of physicians, social
workers, family therapists, employers, teachers, lawyers, and police. Because
the prevalence of harmful and risky substance use far exceeds the capacity of
available services to treat it, briefer and less intensive interventions seem
warranted for a broad range of individuals, including those who are unwilling
to accept referral for more formal and extensive specialized care (Bien et al.,
1993) and those whose substance use is risky but not abusive (Higgins-Biddle
et al., 1997).
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these clinicians reluctant to make clinical changes, but their programs may
also lack the financial and personnel resources to adopt innovative
approaches. Treatment programs limit themselves by such inability and
unwillingness to learn new techniques.
Importance of Evaluation
The Consensus Panel recommends that programs use quality assurance
improvement projects to determine whether the use of a brief intervention or
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2
Brief Interventions in Substance Abuse
Treatment
Brief interventions for substance abuse problems have been used for
many years by alcohol and drug counselors, social workers, psychologists,
physicians, and nurses, and by social service agencies, hospital emergency
departments, court-ordered educational groups, and vocational rehabilitation
programs. Primary care providers find many brief intervention techniques
effective in addressing the substance abuse issues of clients who are unable
or unwilling to access specialty care. Examples of brief interventions include
asking clients to try nonuse to see if they can stop on their own, encouraging
interventions directed toward attending a self-help group (e.g., Alcoholics
Anonymous [AA] or Narcotics Anonymous [NA]), and engaging in brief,
structured, time-limited efforts to help pregnant clients stop using.
Brief interventions are research-proven procedures for working with
individuals with at-risk use and less severe abuse behaviors and can be
successful when transported into specialist treatment settings and performed
by alcohol and drug counselors. As presented in the literature, brief
interventions to change substance abuse behaviors can involve a variety of
approaches, ranging from unstructured counseling and feedback to formal
structured therapy (Chick et al., 1985; Fleming et al., 1997; Kristenson et al.,
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Stages-of-Change Model
The work of Prochaska and DiClemente and their "stages-of-change"
model help clinicians tailor brief interventions to clients' needs (Prochaska
and DiClemente, 1984,1986). Prochaska and DiClemente examined several
theories concerning how change occurs and applied their findings to
substance abuse behavior modification. They devised a model consisting of
five stages of change that seemed to best represent the process people go
through when thinking about, beginning, and trying to maintain new behavior
(see Figure 2-1). The stages-of-change model is explained more fully in TIP
35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT,
1999c).
Figure 2-1
The Stages of Change
Stage
Example
Treatment Needs
Precontemplation.
The user is
not
A functional yet
alcoholdependent
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considering
change, is
aware of few
negative
consequences,
and is unlikely
to take action
soon.
individual who
drinks himself
into a stupor
every night but
who goes to
work every day,
performs his job,
has no substance
abuse-related
legal problems,
has no health
problems, and is
still married.
Contemplation. The
user is aware
of some pros
and cons of
substance
abuse but
feels
ambivalent
about change.
This user has
not yet
decided to
commit to
change.
Preparation. This
stage begins
once the user
has decided to
change and
begins to plan
steps toward
recovery.
An individual who
decides to stop
abusing
substances and
plans to attend
counseling, AA,
NA, or a formal
treatment
program.
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him.
Action. The user
tries new
behaviors, but
these are not
yet stable.
This stage
involves the
first active
steps toward
change.
An individual who
goes to
counseling and
attends meetings
but often thinks
of using again or
may even relapse
at times.
Maintenance. The
user
establishes
new
behaviors on
a longterm
basis.
An individual who
attends
counseling
regularly, is
actively involved
in AA or NA, has
a sponsor, may
be taking
disulfiram
(Antabuse), has
made new sober
friends, and has
found new
substance-free
recreational
activities.
These stages have proven useful, for example, in predicting those most
likely to quit smoking and in targeting specific kinds of interventions to
smokers in different stages (DiClemente et al., 1991; Prochaska, 1999;
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Prochaska and DiClemente, 1986; Velicer et al., 1992). Stages of change are
being examined in brief interventions with hazardous and harmful substance
users as well, as a means of tailoring interventions to the individual's current
stage of change (Hodgson and Rollnick, 1992; Mudd et al., 1995).
Clients need motivational support appropriate to their stage of change.
If the clinician does not use strategies appropriate to the stage the client is in,
treatment resistance or noncompliance could result. To consider change,
clients at the precontemplation stage must have their awareness raised. To
resolve their ambivalence, clients in the contemplation stage must be helped
to choose positive change over their current circumstances. Clients in the
preparation stage need help in identifying potential change strategies and
choosing the most appropriate ones. Clients in the action stage need help to
carry out and comply with the change strategies.
The clinician can use brief interventions to motivate particular
behavioral changes at each stage of this process. For example, in the
contemplation stage, a brief intervention could help the client weigh the costs
and benefits of change. In the preparation stage, a similar brief intervention
could address the costs and benefits of various change strategies (e.g., selfchange, brief treatment, intensive treatment, self-help group attendance). In
the action stage, brief interventions can help maintain motivation to continue
on the course of change by reinforcing personal decisions made at earlier
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stages.
Understanding these stages helps the clinician to be patient, to accept
the client's current position, to avoid "getting too far ahead" of the client and
thereby provoking resistance, and, most important, to apply the correct
counseling strategy for each stage of readiness. Effective brief
interventionists quickly assess the client's stage of readiness, plan a
corresponding strategy to assist her in progressing to the next stage, and
implement that strategy without succumbing to distraction. Indeed, clinician
distraction can be a greater obstacle to change in brief intervention than time
limitations. Regardless of the stage of readiness, brief interventions can help
initiate change, continue it, accelerate it, and prevent the client from
regressing to previous behaviors.
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Figure 2-2
Sample Objectives
Learning to schedule and prioritize time
Expanding a sober support system
Socializing with recovering people or learning to have fun without substance
abuse
Beginning skills exploration or training if unemployed
Attending an AA or NA meeting
Giving up resentments or choosing to forgive others and self
Staying in the "here and now"
Abstainer
Even though abstainers do not require intervention, they can be
educated about substance use with the aim of preventing a substance abuse
disorder. Such prevention education programs are particularly important for
youth.
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At-Risk User
This group includes those whose use is above recommended guidelines
for alcohol use (as described above) or whose use puts them at risk for
problems related to their consumption or at risk for meeting the criteria for a
substance abuse disorder (e.g., people who may be able to report the
requisite number of symptoms of a substance abuse disorder may not have
three or more symptoms within a 12-month period). Brief interventions with
this group address the level of use, encourage moderation or abstinence, and
educate about the consequences of risky behavior and the risks associated
with increased use. Brief interventions can help users understand the
biological and social consequences of their substance use.
Abuser
These are clients with a substance abuse disorder as defined by the
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV)
(American Psychiatric Association [APA], 1994). The goal of intervention with
this population, depending on the clinician's theoretical perspective and the
substances used, is to prevent any increase in the use of substances, to
facilitate introspection about the consequences of risky behavior, to
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Substance-Dependent User
Intervention at this level of use may focus on encouraging users to
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ASAM Criteria
Under ASAM criteria (see Figure 2-3), brief interventions are aimed at
the nondependent user, at level 0.5 or possibly level I. Individuals at level II
may be appropriate for a brief intervention if relapse potential and recovery
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Figure 2-3
American Society of Addiction Medicine (ASAM) Patient Placement Criteria
ASAM has developed client placement criteria for the treatment of substance-related
disorders (1996).
ASAM delineates the following levels of service:
Level 0.5, early intervention
Level I, outpatient services
Level II, intensive outpatient/partial hospitalization services
Level III, residential inpatient services
Level IV, medically-managed intensive inpatient services
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intervention that works well for one client may not work for another. Brief
interventions are components of the journey toward recovery and can be
integral steps in the process. For some clients, assistance with the decision to
make the change will be enough to motivate them to start changing the
behavior, whereas others may need more intensive clinical involvement
throughout the change process. Brief interventions can be tailored to
different populations, and many options are available to augment
interventions and treatments, such as AA, NA, and medications. It should be
noted, however, that brief interventions are not a substitute for specialized
care for clients with a high level of dependency. They can be used to engage
clients in specific aspects of treatment programs, such as attending group and
AA or NA meetings. Brief interventions can also help potential clients move
toward seeking treatment and can serve as a temporary measure for clients
on waiting lists for treatment programs. Even clinicians who advocate
abstinence as a goal can use brief interventions as tools to help clients reach
that goal.
There are six elements critical to a brief intervention to change
substance abuse behavior (Miller and Sanchez, 1994). The acronym FRAMES
was coined to summarize these active ingredients, which are shown in Figure
2-4. The FRAMES components have been combined in different ways and
tested in diverse settings and cultural contexts.
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Figure 2-4
FRAMES
Feedback is given to the individual about personal risk or impairment.
Responsibility for change is placed on the participant.
Advice to change is given by the provider.
Menu of alternative self-help or treatment options is offered to the participant.
Empathic style is used in counseling.
Self-efficacy or optimistic empowerment is engendered in the participant.
Source: Miller and Sanchez, 1993.
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the client and her personal style. Before eliminating steps in the brief
intervention process, however, there should be a well-defined reason for
doing so. Moreover, a vital part of the intervention process is monitoring to
determine how the patient is progressing after the initial intervention has
been completed. Monitoring allows the clinician and client to determine gains
and challenges and to redirect the longer term plan when necessary.
Following are descriptions of the five basic steps. Sample scenarios are
provided where brief interventions might be initiated, with practical
information about that particular step. For each step, Figure 2-5 presents
scripts for brief interventions that clinicians can use in substance abuse
treatment units or other settings where interventions might occur. (For
examples focused on at-risk drinkers, see TIP 24, A Guide to Substance Abuse
Services for Primary Care Clinicians [CSAT, 1997], For detailed descriptions of
more techniques, see TIP 35, Enhancing Motivation for Change in Substance
Abuse Treatment [CSAT, 1999c]).
Figure 2-5
Scripts for Brief Intervention
Component
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Script in the
substance
abuse
treatment
unit
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Introducing the
Issue
"Would it be OK
with you if
we discuss
some of the
difficulties
you've had
in getting
homework
done for the
group
meetings
and how we
can work
together to
help you
take
advantage of
the
treatment
process?"
Screening,
Evaluating,
and
Assessing
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willing to
consider
trying this,
even though
it won't be
easy. Let's
come up
with some
strategies
that we can
write down
to help you
accomplish
this goal."
Providing
Feedback
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Talking About
Change and
Setting Goals
Summarizing and
Reaching
Closure
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In this step, the clinician seeks to build rapport with the client, define
the purpose of the session, gain permission from the client to proceed, and
help the client understand the reason for the intervention.
Counseling tips: Help the client understand the focus of the interview.
State the target topic clearly and stress confidentiality; be nonjudgmental and
avoid labels. Do not skip this opening; without it, the success of the next steps
could be jeopardized.
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Other Drug Abuse and Infectious Diseases; TIP 24, A Guide to Substance Abuse
Services for Primary Care Clinicians; and TIP 31, Screening and Assessing
Adolescents for Substance Use Disorders (CSAT, 1994b, 1994c, 1994d, 1997,
1999a).
Figure 2-6
Screening for Brief Interventions for Alcoholism
Screen
At each visit, ask about alcohol use
How many drinks per week?
Maximum drinks per occasion in past month?
Use CAGE questions to probe for alcohol problems
Have you ever tried to Cut down on your drinking?
Do you get Annoyed when people talk about your drinking?
Do you feel Guilty about your drinking?
Have you ever had an Eye-opener? (i.e. a drink first thing in the morning)
Screen is positive if
Consumption is greater than 14 drinks per week or greater than 4 drinks per
occasion (men)
Consumption is greater than 7 drinks per week or greater than 3 drinks per
occasion (women)
CAGE score is greater than 1
Then assess for
Medical problems: blackouts, depression, hypertension, trauma, abdominal pain,
liver dysfunction, sexual problems, sleep disorders
Laboratory: elevated gamma-glutamyl transpeptidase or other liver function tests;
elevated mean corpuscular volume; positive blood alcohol concentrations
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Counseling tips: Before you begin the brief intervention, decide how
much information you have time to obtain and whether you want to have the
client answer any questionnaires. Watch for defensiveness or other
resistance, and avoid pushing too hard.
Providing Feedback
This component highlights certain aspects of the client's behavior using
information gathered during screening. It involves an interactive dialog for
discussing the assessment findings; it is not just clinician driven. Feedback
should be given in small amounts. First, the clinician gives a specific piece of
feedback, then asks for a response from the client. Sometimes the feedback is
a brief, single sentence; at other times it could last an hour or more. Figure 27 provides an example of giving feedback.
Counseling tips: Use active listening (see "Active listening" later in this
chapter). Be aware of cultural, language, and literacy issues. Be
nonjudgmental.
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Figure 2-7
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Figure 2-8
Talking About Change at Different Stages
In this example, a client who has come to treatment to stop using cocaine has her
alcohol use brought to her attention. At each stage of readiness, the counselor
might use a different strategy. Following are some of the possible scripts that
might be used:
Precontemplation: "Some people find it helpful to ask others in a group if any of them
tried to quit cocaine but continued drinking. If you were to try that with your group,
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express the hope that she will continue to consider committing to changes.
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the clinician, they feel safe to openly discuss their ambivalence about change
rather than resist pressure from the clinician to change before they are
ready to do so. The sooner they address their ambivalence, the sooner they
progress toward lasting change (see also TIP 35, Enhancing Motivation for
Change in Substance Abuse Treatment [CSAT, 1999c]).
When clients feel they are being pushed toward changeeven if the
clinician is not pushingthey are likely to resist. Clients must summon all of
their attention and strength to resolve their ambivalence, and resisting the
clinician may cause them to lose track and argue against change. If the client
and clinician begin arguing or debating, the clinician should immediately shift
to a new strategy, otherwise the brief intervention will fail. In other words,
resistance is a signal for the clinician to change strategies and defuse the
resistance.
Counseling Skills
Active listening
One of the most important skills for brief interventionists is "active
listening" (see Figure 9). Active listening is the ability to accurately restate the
content, feeling, and meaning of the client's statements. This is also called
"reflective listening," "reflecting," or sometimes "paraphrasing." Active
listening is one of the most direct ways to rapidly form a therapeutic alliance.
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Figure 2-9
Steps in Active Listening
1. Listen to what the client says.
2. Form a reflective statement. To reflect your understanding, repeat in your own words
what the client said.
3. Test the accuracy of your reflective statement. Watch, listen, and/or ask the client to
verify the accuracy of the content, feeling, and/or meaning of the statement.
Skilled active listeners perform these three steps automatically, naturally,
smoothly, and quickly. Active listening saves time by reducing or preventing
resistance, focusing the client, focusing the clinician, encouraging self-disclosure,
and helping the client remember what was said during the intervention.
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Another important skill is the ability to help clients explore and resolve
ambivalence. Ambivalence is the hallmark of a person in the contemplation
stage of readiness. It is one of the most prevalent clinical challenges
encountered in brief interventions. Whether it takes 1 minute or 40 minutes,
the goal is to help clients become more aware of their position and the
discomfort that accompanies their ambivalence. Increasing awareness of this
discomfort within an understanding and supporting relationship can inspire
the client to progress to a stage of preparation or action. For example, a client
might be willing to go to counseling but not an AA meeting; in that case, the
clinician should work with the client's motivation and focus on the positive
step the client is willing to make.
One way to help a client recognize his ambivalence is to ask him to
identify the benefits and costs of the targeted behavior (e.g., using alcohol)
and the benefits and costs of changing the behavior. The clinician listens and
summarizes these benefits and costs, then asks the client if any of them is
more important than the others. This helps identify values that are important
to the client and can therefore increase or decrease the chance of changing.
Clinicians might also ask if any of the pros and cons is more or less accurate
than others. This provides an opportunity for irrational thoughts to be
refuted, which can help remove barriers to change (see example in the text
box below).
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Figure 2-10
Professionals Outside of Substance Abuse Treatment Who Can Administer Brief
Interventions
Primary care physicians
Substance abuse treatment providers
Emergency department staff members Nurses
Social workers
Health educators
Lawyers
Mental health workers
Teachers
EAP counselors
Crisis hotline workers, student counselors
Clergy
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treatment must be flexible when assessing, planning, and carrying out brief
interventions. For example, they will likely encounter more risky drinkers
than alcohol-dependent individuals (in the United States there are four times
as many risky drinkers as dependent drinkers [Mangione et al., 1999]). Some
research indicates that the potential for brief interventions to reduce the
harm, problems, and costs associated with moderate to heavy alcohol use by
risky drinkers significantly surpasses the effectiveness from applications of
brief interventions on substance-dependent individuals (Higgins-Biddle et al.,
1997). Other research on brief interventions, as presented below, highlights
some of the more rigorous studies with positive outcomes. The costs of
alcohol abuse to society, as interpreted by health care costs, lost productivity,
and criminal activity, are enormous, and brief interventions are a costeffective technique to address such abuse. Typically these brief interventions
act as an early intervention before or close to the development of alcoholrelated problems and primarily entail instructional and motivational
components addressing drinking behavior. In substance abuse treatment,
brief interventions are used to assist in the treatment engagement process
and to deal with specific individual, family, or treatment-related issues.
When delivering a brief intervention in any treatment setting, the
provider should be mindful of room conditions and interruptions because
client confidentiality is of utmost importance. Federal law requires that chart
notes or other records on substance abuse be kept apart from the rest of the
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client's main chart. For example, if a medical client in a primary care clinic is
also seen by an alcohol and drug counselor for treatment of a substance abuse
disorder, those medical records are strictly protected by Federal law and may
not be put in the client's chart. (For more information on these Federal laws,
see TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians
[CSAT, 1997].)
Heather makes an important distinction between brief interventions
that are delivered in opportunistic settings where patients are not directly
seeking help for a substance abuse disorder and those conducted in
treatment environments where patients are seeking the help of specialists
(Heather, 1995). Brief interventions conducted in opportunistic settings tend
to be shorter, rely less on theory and more on an existing clinician-client
relationship, and are less expensive because they are offered as part of an
existing service.
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Research Findings
Brief interventions for substance abuse have been implemented since
the 1960s. The literature in this area includes theoretical articles, clinical case
studies and recommendations, quasi-experimental studies, and randomized
controlled experimental research trials. Many of the brief intervention clinical
trials have been conducted in the United States and Europe since the early
1980s, and most have focused on alcohol use. There is some experimental
research on brief interventions for drug use but very little has been published
to date. This is an area of ongoing and future work.
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published from 1972 to 1994. Another, more recent review (Wilk et al., 1997)
culled nearly 6,000 articles from MEDLINE and PsychLIT searches from 1966
to 1995 to find 99 that met criteria for closer inspection. A total of 11 of the
articles found by Kahan and colleagues and 12 of those reviewed by Wilk and
associates had control groups, adequate sample sizes, and specified criteria
for brief interventions.
The most recent reviews of brief intervention studies concluded that
brief interventions have merit, especially for carefully selected clients and can
be applied successfully in several settings for different purposes (Bien et al.,
1993; Kahan et al., 1995; Mattick and Jarvis, 1994; Wilk et al., 1997). The
review by Bien and colleagues was one of the first to categorize brief
interventions and evaluate their effectiveness according to the stated goals
and settings in which they were conducted. After examining 12 controlled
studies of strategies to improve clients' acceptance of referrals for additional
specialist treatment or return to the clinic for additional treatment following
an initial visit, Bien and colleagues concluded that relatively simple strategies
and specific aspects of counselors' styles can increase rates of follow-through
on referrals as well as improve initial engagement and participation in
treatment (Bien et al., 1993). Only one unsuccessful trial of referral
procedures is described, and the failure is attributed to the fact that all
subjects had previously failed to respond to brief advice about getting into
treatment for alcoholism.
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simple advice had more severe alcohol problems and higher consumption
patterns.
Another interesting finding from the WHO study was that female
participants in all groups had reduced their drinking at 9 months, regardless
of whether they received any intervention. One explanation may be that the
female participants were only recruited from two relatively affluent countries
Australia and the United Statesthus, the results cannot be generalized to
all
women
(Sanchez-Craig,
1994).
Furthermore,
the
20-minute
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al., 1980,1981; Miller and Munoz, 1982), and Norway (Skutle and Berg, 1987)
essentially replicated the results of previous positive trials, comparing brief
interventions favorably with a variety of extended treatments for problem
drinking (including cognitive-behavior therapies, marital therapy,
confrontational counseling, and standard inpatient and outpatient treatment).
Sanchez-Craig and colleagues found that when comparing the 12-month
treatment outcomes of severely dependent and nonseverely dependent men
receiving brief treatment in Toronto and Brazil, there were no significant
differences in "successful" outcomes as measured by rates of abstinence or
moderate drinking (Sanchez-Craig et al., 1991). The IOM also noted that rates
of spontaneous remission of alcoholism suggest that some portion of the most
severe alcoholic population will reduce or discontinue their drinking without
formal intervention (IOM, 1990).
The largest multisite NIAAA-sponsored study of treatment matching
and outcomes, Project MATCH (Matching Alcoholism Treatment to Client
Heterogeneity), compared the effects of treatment type on outcomes for more
than 1,500 alcohol-dependent patients (Project MATCH Research Group,
1997,1998). Treatment types included (1) four 1-hour sessions of
motivational enhancement therapy, which is often considered a brief
intervention even though it is more intensive than most brief interventions
(NIAAA, 1995), (2) 12 sessions of 12-Step facilitation, and (3) 12 sessions of
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Methodological Issues
Issues are frequently raised regarding specific methodological concerns
of studies on brief interventions. First, many of the brief intervention studies,
particularly those focused on alcohol, rely on self-report data to determine
outcomes. The validity of measuring alcohol and other use by self-report is
routinely questioned; however, reviewers of relevant literature have
concluded that these data are generally valid and reliable (Midanik, 1982;
Sobell and Sobell, 1990). Reports from collaterals, such as family members,
are not as reliable except for highly visible events, such as drinking-related
arrests (Midanik, 1982). Persons with hazardous drinking patterns will
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provide accurate information about their use, particularly under the following
conditions: (1) the setting is a research or clinical one, (2) confidentiality is
assured, and (3) the interview is administered when the respondent is sober
(Sobell and Sobell, 1990). Techniques to increase the accuracy of self-reports
have been employed in recent studies (Fleming et al., 1997,1999). These
studies use interviewers who fully understand drinking-related questions and
can explain confusion about common terms (e.g., "blackouts," "high").
Concerns about the methodological limitations of some trials have
included sample sizes that were too small and a statistical power insufficient
to reliably detect differences between effects in the groups compared (Bien et
al., 1993; Mattick and Jarvis, 1994). There may be differential attrition in
groups at followup, and these dropouts can be ignored or excluded from
analyses (Bien et al., 1993; Drummond, 1997; Kahan et al., 1995), or there
could be contamination because the comparison group could be seeking
additional treatment during the course of the research (Bien et al., 1993;
Kahan et al., 1995; Mattick and Jarvis, 1994). Also, randomization of samples
has not always been conducted (Wilk et al., 1997), and some early studies did
not have control groups or did not have an adequate comparison group (Bien
et al., 1993). Some of the newer brief intervention studies have addressed
many of these concerns (Fleming et al., 1997,1999). These, however, remain
issues that must be addressed by new studies of brief intervention techniques
with special populations and with new technology.
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3
Brief Therapy in Substance Abuse Treatment
Brief therapy is a systematic, focused process that relies on assessment,
client engagement, and rapid implementation of change strategies. Brief
therapy providers can effect important changes in client behavior within a
relatively short period. The brief therapies presented in this TIP should be
seen as contained modalities of treatment, not episodic forms of long-term
therapy.
However, in the literature and in practice, the term "brief therapy"
covers a wide range of approaches to treatment of varying lengths and with a
variety of goals. Brief therapies usually consist of more (as well as longer)
sessions than brief interventions. The duration of brief therapies is reported
to be anywhere from 1 session (Bloom, 1997) to 40 sessions (Sifneos, 1987),
with the typical therapy lasting between 6 and 20 sessions. Twenty sessions
usually is the maximum because of limitations placed by many managed care
organizations. Any therapy may be brief by accident or circumstance, but the
focus of this TIP is on planned brief therapy. The therapies described here
may involve a set number of sessions or a set range (e.g., from 6 to 10
sessions), but they always work within a time limitation that is clear to both
therapist and client. In the following pages, all therapies described should be
understood as planned or time limited.
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Research Findings
Research concerning the relative effectiveness of brief versus longer
term therapies for a variety of presenting complaints is mixed. Some studies
have found that planned, short-term therapies are as effective as lengthier (or
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unlimited) therapy (Koss and Shiang, 1993; Smyrnios and Kirkby, 1993).
Other studies, such as the Consumer Reports mental health study (Seligman,
1995) and the National Institute of Mental Health (NIMH) Treatment of
Depression Research Program (Blatt et al., 1995; Elkin, 1994), have found
that longer term treatments generally lead to better outcomes as perceived
by clients. Much depends on the modality being evaluated and the goals of the
treatment. (More specific research evaluating different types of brief therapy
is given in Chapters 4 to 9.)
There is, however, promising evidence that brief therapies as a
treatment for substance abuse disorders are often as effective as lengthier
treatments (Bien et al., 1993; Gottheil et al., 1998; McLellan et al., 1993; Miller
and Hester, 1986a; Miller and Rollnick, 1991). These studies are positive but
are primarily limited to program effectiveness studies with smaller sample
sizes. Future research should both replicate previous work and use more
rigorous designs that include experimental designs with randomization. Many
of the fundamental questions about brief therapiesthe optimum conditions
under which they should be used, the economic cost-benefits, and level and
type of provider, the most suitable types of clientshave yet to be studied.
The majority of clients in therapy (regardless of the modality) remain in
treatment for between 6 and 22 sessions; 90 percent end treatment before
completing 20 visits (Friedberg, 1999). The fact that many clients stay in
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therapy for relatively short periods of time suggests that brief therapy
techniques should be much more common than they are in current clinical
practice (Pekarik and Wierzbicki, 1986; Phillips, 1987). Many therapists
trained in long-term treatment modalities choose not to use planned shortterm therapies (Bloom, 1997). Alcohol and drug counselors often have to
work with clients in a limited period of time, however, and could apply brief
therapy techniques even when they are designed for treatment of different
types of disorders and problems.
Because brief therapy is more effective than being on a waiting list, it
could benefit many clients. Wolberg suggested that all clients seeking
treatment be given brief therapy initially, before moving on to long-term
treatments (Wolberg, 1980). Such an approach would help to reserve longer
treatments for clients with a greater need for them. However, there are
clearly exceptions to this rule, such as clients who have a history of severe
and persistent mental illness. Other criteria for assigning a client to longer
term rather than brief therapy are presented in Figure 3-1.
Figure 3-1
Criteria for Longer Term Treatment
The following criteria can help identify clients who could benefit from longer term
treatment:
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Figure 3-2
Selected Criteria for Providing Brief Therapy
Dual diagnosis issues such as a coexisting psychiatric disorder or developmental
disability
The range and severity of presenting problems
The duration of abuse
Availability of familial and community supports
The level and type of influence from peers, family, and community
Previous treatment or attempts at recovery
The level of client motivation (brief therapy may require more work on the part of the
client but a less extensive time commitment)
The clarity of the client's short- and long-term goals (brief therapy will require more
clearly defined goals)
The client's belief in the value of brief therapy ("buy in")
Large numbers of clients needing treatment
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Less severe substance abuse, as measured by an instrument like the Addiction Severity
Index (ASI)
Level of past trauma affecting the client's substance abuse
Insufficient resources available for more prolonged therapy
Limited amount of time available for treatment (e.g., 7-day average length of stay in
county-jail-level correctional facilities; 30-to 45-day limitation in Job Corps
program)
Presence of coexisting medical or mental health diagnoses
Large numbers of clients needing treatment leading to waiting lists for specialized
treatment
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Currently, the most widely used model for understanding clients' readiness
for change is Prochaska and DiClemente's stages-of-change model, which is
discussed in Chapter 2. (For more information about this model, see also TIP
35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT,
1999c].) Counselors who use this model will have to determine which
therapy is compatible with the client's stage of readiness for change and the
tasks needed to move forward in the change process and develop an overall
understanding of the course of change (DiClemente and Scott, 1997).
Clinical interventions should be targeted to the client's stage of
readiness for change to increase his motivation to change behaviors and to
augment a sense of empowerment in recovery. Therapies that work with
experiential processes (such as consciousness raising, self reevaluation, and a
cognitive restructuring) are more important for understanding and
predicting transition from preparation to action and from action to
maintenance (Prochaska et al., 1994). Seeking and processing information,
observing others, and gathering useful information in light of the client's
situation are the primary activities reported most frequently during the
contemplation stage (Prochaska et al., 1994). Especially during this early
stage the client should be provided with information regarding addiction as
well as confronted with the short- and long-term consequences of continued
use. Asking the client to perform a risk appraisal of continued use as well as a
benefit/risk-reduction appraisal of achieving abstinence can facilitate sound
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Figure 3-3
Approaches to Brief Therapy
Approaches
Description
Cognitive therapy
Behavioral therapy
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Strategic/interactional
therapies
Solution-focused therapy
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Psychodynamic therapy
Interpersonal therapy
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Group therapy
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Figure 3-4
Characteristics of All Brief Therapies
They are either problem focused or solution focused; they target the symptom and not
what is behind it.
They clearly define goals related to a specific change or behavior.
They should be understandable to both client and clinician.
They should produce immediate results.
They can be easily influenced by the personality and counseling style of the therapist.
They rely on rapid establishment of a strong working relationship between client and
therapist.
The therapeutic style is highly active, empathic, and sometimes directive.
Responsibility for change is placed clearly on the client.
Early in the process, the focus is to help the client have experiences that enhance selfefficacy and confidence that change is possible.
Termination is discussed from the beginning.
Outcomes are measurable.
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Screening does not inform the therapist of the severity of the individual
client's substance abuse, only its presence and, in some cases, broad
indications of risk. Screening identifies the need for more in-depth
assessment and is not a substitute for an assessment.
Assessment is a thorough, extensive process that involves a broad
analysis of the factors contributing to and maintaining a client's substance
abuse, the severity of the problem, and the variety of consequences
associated with it. Screening and assessment procedures for brief therapy do
not differ significantly from those used for lengthier treatments.
The assessment should determine whether the client's substance abuse
problem is suitable for a brief therapy approach. The criteria for determining
the appropriateness of brief therapy, presented in Figures 3-1 and 3-2, are
first applied during the assessment stage.
It is reasonable to assume that brief therapies are most effective with
clients whose problems are of short duration and who have strong ties to
family, work, and community. However, limited client resources may also
dictate the use of brief therapy. For example, if a client lacks the financial
means to participate in a longer treatment process, a brief therapy approach
is imperative. Some treatment is almost always better than no treatment. In
addition, brief therapy may be indicated for clients who resist longer
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Figure 3-5
Sample Battery of Brief Assessment Instruments
Assessment Domain
Example Instrument(s)
Quantity/frequency of
use
Severity of dependence
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Consequences of use
Readiness to change
Problem areas
Treatment placement
Intentions Questionnaire
For brief therapy, the setting in which treatment will occur frequently
dictates the kind of assessment that can be conducted. Clients seek treatment
in the type of agency they feel will best meet their needs (e.g., those who need
to continue working while seeking treatment will likely enter an outpatient
program). Constraints may be placed by insurance companies or other
outside forces. For example, managed care environments generate their own
assessment criteria. Assessment often must be conducted outside the
treatment facility and may not qualify as a reimbursable visit. In addition,
private practitioners often do not have easy access to background
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Goals of treatment
Therapists should identify and discuss the goals of brief therapy with
the client early in treatment, preferably in the first session. The client has a
critical role in determining the goals of therapy, and the therapist might have
to be flexible. The therapist can recommend treatment goals, but ultimately
they are established through interaction and negotiation with the client. If a
client has certain expectations of therapy that make it difficult for her to
commit to the goals and procedures of brief therapy or to a particular
therapeutic approach, other approaches should be considered or a referral
made.
Treatment goals should focus on the central problem of substance abuse
and may include the following:
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Subsequent Sessions
In subsequent sessions of brief therapy, therapists should
Work with the client to help maintain motivation and address
identified
problems,
monitoring
whether
any
accomplishments are consistent with the treatment plan and
the client's expectations
Reinforcethrough an ongoing review of the treatment plan and
the client's expectationsthe need to do the work of brief
therapy (e.g., maintain problem focus, stay on track)
Remain prepared to rapidly identify and troubleshoot problems
Maintain an emphasis on the skills, strengths, and resources
currently available to the client
Maintain a focus on what can be done immediately to address
the client's problem
Consider, as part of an ongoing assessment of progress, whether
the client needs further therapy or other services and how
these services might best be provided
Review with the client any reasons for dropping out of treatment
(e.g., medical problems, incarceration, the emergence of
severe psychopathology, treatment noncompliance)
Maintenance Strategies
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Maintenance strategies must be built into the treatment design from the
beginning. A practitioner of brief therapy must continue to provide support,
feedback, and assistance in setting realistic goals. Also, the therapist should
help the client identify relapse triggers and situations that could endanger
continued sobriety.
Strategies to help maintain the progress made during brief therapy
include the following:
Educating the client about the chronic, relapsing nature of
substance abuse disorders
Developing a list of circumstances that might provide reasons for
the client to return to treatment and plans to address them
Reviewing problems that emerged but were not addressed in
treatment and helping the client develop a plan for addressing
them in the future (or identifying specific problems that might
have emerged but were not dealt with in treatment)
Developing strategies for identifying and coping with high-risk
situations or the reemergence of substance abuse behaviors
Teaching the client how to capitalize on personal strengths
Emphasizing client self-sufficiency (encouraging the client to
work through his own problems and stay focused on the goals
that have been set in therapy) and teaching self-
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reinforcement techniques
Developing a plan for future support, including mutual help
groups, family support, and community support (e.g.,
religious or social service organizations), which can be done
much earlier than in longterm therapy
In addition to routine progress assessments that are conducted
throughout the therapy, midway through the agreed-upon number of
sessions the therapist should formally review the client's progress.
Particularly because of the time limitations of brief therapy, continuing
assessments are essential to ensure that problems are addressed and that the
client can recognize when she is most at risk of slipping into substance abuse
or other negative behaviors. Assessments will also take into account the level
of the client's progress. When the client has made agreed-upon behavior
changes and has resolved some problems, the therapist should prepare to end
the brief therapy. If a client progresses more quickly than anticipated, it is not
necessary to complete the full number of sessions.
Ending Treatment
Termination of therapy should always be planned in advance. In many
types of brief therapy, the end of therapy will be an explicit focus of
discussion in which the therapist should
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treatment, not just at the end of the treatment process. Reasons for initiating
referrals during or at the end of treatment include the following:
The client needs ancillary services for other problems that have
been recognized during therapy (e.g., medical or psychiatric
problems).
The client requires more intensive therapy.
The client may benefit from involvement with a support group,
such as Alcoholics Anonymous, Self-Management and
Recovery Training (SMART), or Moderation Management
(which may also be a part of the brief therapy process).
Followup
It is always advisable for the therapist to follow up with clients who
have completed brief therapy. Followup reassures the client that the therapist
is concerned about her progress. In addition, it is an effective way to gather
much-needed data regarding treatment effectiveness. The therapist might
obtain such data by conducting a client satisfaction survey via telephone or
mail. Aftercare, when additional treatment is provided, is not part of the brief
therapy process. However, followup activities such as offering reassurance
and tracking client status are customary.
Therapist Characteristics
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Brief Cognitive-Behavioral Therapy
An approach that has gained widespread application in the treatment of
substance abuse is cognitive-behavioral therapy (CBT). Its origins are in
behavioral theory, focusing on both classical conditioning and operant
learning; cognitive social learning theory, from which are taken ideas
concerning observational learning, the influence of modeling, and the role of
cognitive expectancies in determining behavior; and cognitive theory and
therapy, which focus on the thoughts, cognitive schema, beliefs, attitudes, and
attributions that influence one's feelings and mediate the relationship
between antecedents and behavior. Although there are a number of
similarities across these three seminal perspectives (see Carroll, 1998), each
has contributed unique ideas consistent with its theoretical underpinnings.
However, in most substance abuse treatment settings, the prominent features
of these three theoretical approaches are merged into a cognitive-behavioral
model.
Before focusing more specifically on the cognitive-behavioral model,
this chapter examines the behavioral and cognitive theories and therapies
that serve as the foundations of and have contributed significantly to the
cognitive-behavioral approach to substance abuse treatment. Both behavioral
and cognitive theories have led to interventions that individually have been
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Behavioral Theory
In contrast to many other methods, behavioral approaches to the
treatment of substance abuse have substantial research evidence in support
of their effectiveness. Two recent comprehensive reviews of the treatment
research literature offer strong evidence for their effectiveness (Holder et al.,
1991; Miller et al., 1995). However, some critics argue that this is because
behavioral approaches have been developed under controlled conditions and
that in "real" therapy there are many more variables at work than can be
measured in controlled experiments. Providers should take advantage of the
wide range of behavioral therapy techniques that are available. These
techniques can be conducted successfully in individual, group, and family
settings, among others, to help clients change their substance abuse
behaviors.
Behavioral approaches assume that substance abuse disorders are
developed and maintained through the general principles of learning and
reinforcement. The early behavioral models of substance abuse were
influenced primarily by the principles of both Pavlovian classical conditioning
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and Skinnerian operant learning (O'Brien and Childress, 1992; Stasiewicz and
Maisto, 1993). (See Figure 4-1 for definitions of classical conditioning and
operant learning.)
Figure 4-1
Classical Conditioning and Operant Learning
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Figure 4-2
Basic Assumptions of Behavioral Theories of Substance Abuse and Its
Treatment
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Figure 4-3
Advantages of Behavioral Theories in Treating Substance Abuse Disorders
Flexible in meeting specific client needs
Readily accepted by clients due to high level of client involvement in treatment
planning and goal selection
Soundly grounded in established psychological theory
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By its very design, most behavioral therapy is brief. The aim is not to
remake personality, but rather to help the client address specific, identifiable
problems in such a way that the client is able to apply the basic techniques
and skills learned in therapy to the real world, without the assistance of the
therapist. Behavioral therapy focuses more on identifying and changing
observable, measurable behaviors than other therapeutic approaches and
hence lends itself to brief work. Treatment is linked to altering the behavior,
and success is the change, elimination, or enhancement of particular
behaviors.
Regular assessment and measurement of progress are integral to
effective behavioral therapy. Decisions about the length of treatment are
made on the basis of these assessments, rather than according to a formula or
theoretical assumption about how long therapy should take. Each individual
is approached as a unique case, albeit one to which broad principles can be
applied.
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proceeds further in imagining entering the bar, sitting down, ordering a drink,
and so on, the initial sense of craving shifts to mild discomfort. As he
visualizes beginning to take a drink and tastes the alcohol, he is then asked to
imagine becoming violently sick and vomiting (Rimmele et al., 1995).
While aversive conditioning procedures have most often been used in
the treatment of alcohol dependence, they have also been applied to the
treatment of marijuana and cocaine use (Frawley and Smith, 1990; Smith et
al., 1988). It should be noted that these aversive conditioning techniques, as
well as cue exposure approaches, are best viewed as components of a more
comprehensive treatment program rather than as independent, free-standing
treatments (O'Brien, et al., 1990; Smith and Frawley, 1993). In this context,
Smith and colleagues reported positive outcomes for dependent users of both
alcohol and cocaine who received chemical aversion procedures as part of
their treatment in comparison to those who did not receive similar treatment
(Frawley and Smith, 1990; Smith et al., 1997). Rimmele and colleagues also
recommended covert sensitization as a highly effective and portable
treatment component which, unlike chemical or electric aversion therapies,
can be used at any time and in any setting as a self-control strategy (Rimmele
et al., 1995).
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Figure 4-4
Functional Analysis
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behavior or not, and the timeframe in which the desired behavior change is to
occur. The act of composing and signing a contract is a small but potentially
important ritual signifying the client's commitment to the proposed change.
In the contract, the client may include contingencies, especially rewards or
positive incentives that will reinforce target behaviors (e.g., attending
treatment sessions, getting to 12-Step meetings, avoiding stimuli associated
with substance use). Goals should be clearly defined, broken into small steps
that occur frequently, and revised as treatment progresses; contingencies
should occur quickly after success or failure.
Most often, behavioral contracts and contingency management
procedures are embedded in a more comprehensive treatment program.
Contracts targeting goals supportive of recovery (e.g., improving vocational
behavior, saving money, being prompt for counseling, regularly taking
medication) are generally more likely to be achieved and lead to better
outcomes than those more directly related to substance use (e.g., clean urine
samples) (Anker and Crowley, 1982; Iguchi et al., 1997; Magura et al., 1987,
1987). For instance, research found that receiving vouchers contingent on
completing objective, individually tailored goals related to one's overall
treatment plan was more effective in reducing substance abuse than either a
voucher system specifically targeting drug-free urine samples or a standard
treatment without either of these contingency contracts added (Iguchi et al.,
1997). The effectiveness of such contracts also appears to be linked to the
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Initial session
The initial session in brief behavioral therapy involves an exploration of
the reasons the client is seeking treatment at this particular time; the extent
to which this motivation for treatment is intrinsic, rather than influenced by
external sources; the areas of concern that the client and significant others
may have about his substance abuse; the situations in which she drinks or
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uses excessively; and the consequences she experiences (both positive and
negative, as well as proximal and removed from the actual substance abuse).
This involves an abbreviated functional analysis. (See the section with that
name later in this chapter.)
The information gained in the session will assist the counselor in
determining the antecedents that prompt substance abuse and the
reinforcers that appear to maintain it. Based on the information obtained, the
counselor can begin to formulate a treatment plan with respect to the specific
target behaviors to address, the behavioral interventions that address these
target behaviors most effectively, and behaviors incompatible with heavy
drinking that should be reinforced and targeted for an increase in frequency.
During the initial session, the therapist should note the most salient
problems identified by the client and intervene with them first. The therapist
also should assess the client's readiness to change and then develop initial
behavioral goals in collaboration with the client. For substance abuse
disorders, these goals will, of course, involve a reduction in or cessation of
substance use. In addition to targeting substance abuse as the primary focus,
other goals will be developed to assist the client in improving daily
functioning (e.g., by reducing stress, as described in Figure 4-5). The focus of
the therapy might be to negotiate with the client to accomplish these other
goals by reducing use. The therapist will continue to engage the client in a
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Figure 4-5
Teaching Stress Management
The client learns methods that will help her reduce stress, including relaxation
techniques, systematic desensitization, planning in advance for a potentially
stressful event, and cognitive strategies. These techniques can help in resisting
the temptation to abuse substances in otherwise stressful situations. While it
does not seem that all clients with substance abuse disorders face increased
stress (Cappell, 1987), for those who do, stress management techniques (such as
those described by Stockwell, 1995) can prove useful.
Near the end of the initial session the therapist reviews with the client
the procedure for filling out the self-monitoring records. In addition, the
therapist might provide the client with self-help manuals that outline the
specific steps in the behavioral self-control process. Self monitoring of
substance abuse behavior is one form of written homework common in
behavioral approaches; other types of homework might also be used.
Homework assignments can include such things as keeping a journal of
behaviors, activities, and feelings when using substances or at risk of doing
so. In the brief behavioral model designed by Phillips and Weiner, techniques
such as programmed therapy and writing therapy (see Figure 4-6) make what
is typically thought of as "homework" the central concern of the therapy
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Figure 4-6
Programmed Therapy and Writing Therapy
These techniques lend themselves to brief therapy because they reduce the role
of the therapist and increase the amount of work required from the client.
Phillips and Weiner developed these techniques as stand-alone approaches to
treatment (Phillips and Weiner, 1966). However, they can also be used as
adjuncts to other forms of treatment and may be incorporated into the
homework assignments that many therapists already are using. In programmed
therapy, the client interacts with written or computerized instructions and tests
that work to teach the client new behaviors, much in the way students might
learn a subject from a textbook. Writing therapy involves having the client come
in at a designated time each week to write for 1 hour in a notebook which the
therapist then reads and responds to in writing. No one but the therapist and the
client should have access to the notebook. Writing therapy is a technique that
may be particularly useful for clients who have difficulty talking about their
thoughts and feelings.
Later sessions
Based on a review of the information collected through self-monitoring,
subsequent sessions involve negotiation about treatment goals. While many
problem drinkers, for example, choose a moderation goal, across time those
with more severe problems shift to a goal of abstinence (Hodgins et al., 1997).
Later sessions might also consider the introduction of cue exposure training
or relapse prevention targeted at substance abuse above a particular level.
These behavioral techniques have been incorporated into more
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Cognitive Theory
Cognitive theory assumes that most psychological problems derive from
faulty thinking processes (Beck and Wright, 1992; Beck et al., 1993; Beck and
Liese, 1998; Ellis, 1982; Ellis et al., 1988). The diagram in Figure 4-7
illustrates the three bidirectional components of this theory. (1) cognitions or
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thoughts, (2) affect or feelings, and (3) behavior. While cognitive theory owes
a debt to the behavioral model, the differences are apparent. Unlike
behavioral models that focus primarily on observable behaviors, cognitive
theory views antecedent events, cognitions, and behavior as interactive and
dynamic, as indicated by the double-headed arrows (depicted in Figure 4-7).
Each of these components is capable of affecting the others, but the primary
emphasis is placed on cognition. The way we act and feel is most often
affected by our beliefs, attitudes, perceptions, cognitive schema, and
attributions. These cognitive factors serve as a template through which
events are filtered and appraised. To the extent that our thinking processes
are faulty and biased, our emotional and behavioral responses to what goes
on in our life will be problematic. According to this theory, changing the way a
client thinks can change the way he feels and behaves.
Figure 4-7
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Figure 4-8
Fifteen Common Cognitive Errors
1. Filteringtaking negative details and magnifying them, while filtering out all
positive aspects of a situation
2. Polarized thinkingthinking of things as black or white, good or bad, perfect or
failures, with no middle ground
3. Overgeneralizationjumping to a general conclusion based on a single incident or
piece of evidence; expecting something bad to happen over and over again if
one bad thing occurs
4. Mind readingthinking that you know, without any external proof, what people
are feeling and why they act the way they do; believing yourself able to discern
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Figure 4-9
Characteristic Thinking of People With Substance Abuse Disorders
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Qualitative Descriptors
Automatic, nonconscious
Rigid, inflexible
Overlearned and often practiced
Dichotomous, all-or-none
Overgeneralized and illogical
Nonempirical and absolute
Common Content or Themes
Denial: alcohol or drugs are not a problem
Alcohol or drugs are the best and only way to solve emotional problems
Low frustration tolerance and/or self-defined needs for high levels of stimulation,
gratification, and excitement
Discomfort anxiety: all negative emotions are to be avoided at all costs
Change is too difficult, therefore one is hopeless, helpless, worthless
Self-blame, guilt, and shame for being an addict
Source: Adapted from Ellis et al., 1988.
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particularly feeling doomed about the past were predictive of both the
frequency of drinking and the average quantity of alcohol consumed
following substance abuse treatment (Rohsenow et al., 1989).
Cognitive Therapy
Given the view that dysfunctional behavior, including substance abuse,
is determined in large part by faulty cognitions, the role of therapy is to
modify the negative or self-defeating automatic thought processes or
perceptions that seem to perpetuate the symptoms of emotional disorders.
Clients can be taught to notice these thoughts and to change them, but this is
difficult at first. Cognitive therapy techniques challenge the clients'
understanding of themselves and their situation. The therapist helps clients
become more objective about their thinking and distance themselves from it
when recognizing cognitive errors or faulty logic brought about by automatic
thinking.
Treatment, therefore, is directed primarily at changing distorted or
maladaptive thoughts and related behavioral dysfunction. Cognitive
restructuring is the general term given to the process of changing the client's
thought patterns. Figure 4-10 shows a number of distorted addictive thoughts
and more rational alternatives that the therapist might help develop and
practice over the course of cognitive restructuring.
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Figure 4-10
Common Irrational Beliefs About Alcohol and Drugs With More Rational
Alternatives
Irrational Belief
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Figure 4-11
Thoughts, Feelings, and Behaviors
Thought
Feeling
Behavior
Desire to feel
good
The maladaptive thought in this triad should be replaced in order to avoid the
consequent behavior.
"I can feel good by jogging or taking a
walk, or..."
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Desire to feel
good
Walking, running
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of her beliefs. Thus, Beck places more importance on the client's own
discovery of faulty and unproductive thinking, while Ellis believes that the
client should simply be told that these exist and what they are. Nevertheless,
there is substantial overlap in both the theory and practice of these two
therapies. Clearly, different clients will have different responses to these
qualitatively different approaches to modifying their thoughts and beliefs.
Therapeutic work in cognitive therapy is devoted primarily, although
not exclusively, to addressing specific problems or issues in the client's
present life, rather than global themes or long-standing issues. At times,
however, it is important to understand the connection between the origins of
a set of cognitions and the client's current behavior. Such an understanding of
how the individual got to the present emotional and behavioral state is often
essential to understanding the mechanism of change. The client's attention to
current problems is intended to promote her development of a plan of action
that can reverse dysfunctional thought processes, emotions, and behavior
such as avoidance of problems or feelings of helplessness. Clients are enlisted
as coinvestigators or scientists who study their own thought patterns and
associated consequences.
Cognitive therapy can be useful in the treatment of substance abuse
disorders in several ways. When distorted or unproductive ways of thinking
about daily life events lead to negative emotional states that then promote
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Initial Session
Cognitive therapy works under the assumption that a client can be
educated to approach his problems rationally. Because of this emphasis on
rational understanding, the cognitive therapist will typically begin therapy by
explaining the nature of her approach (see Figure 4-12 for a sample opening
script).
In the opening session of cognitive therapy, the therapist will assess the
client's view of his problems and their causes. The therapist pays careful
attention to the meaning the client assigns to significant events and how that
meaning is related to subsequent feelings and unwanted behavior. In the
middle to late phases of the first session, the therapist will emphasize the
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Figure 4-12
Introducing Cognitive Therapy: A Sample Script
"I want to spend a few minutes telling you about my approach. Basically, it comes
from the observation by many people that our feelings and behaviors in
particular situations follow directly from how we think about these situations.
My goal in working with you is to focus on trying to understand how you see
thingsthe important things in your life that are related to substance useand
to help you look at them objectively and honestly. We may find that you are
seeing them correctly, and we'll have to address these realities. Sometimes,
though, people get into automatic ways of thinking about themselves and their
situation without examining them more carefully. Let's look at these possibilities
and see if they can be changed to help you. How does that sound to you?"
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Later Sessions
Cognitive therapy tends to follow a standard within-session structure to
make the maximum use of time, to focus on the most important current
problems, to set the tone for a working atmosphere, and to maintain
continuity between sessions. Beck structures sessions into eight elements,
listed below, which he describes in greater detail (Beck et al., 1993):
1. Setting the agendato focus on primary goals for treatment
2. Mood checkto monitor the feelings of the client, especially changes
3. Bridge from last sessionto maintain continuity between sessions
4. Discussion of today's agendato prioritize topics, avoid irrelevant
tangents, determine the best possible use of time, and solicit the
client's topics for discussion
5. Socratic questioningto encourage the client to contemplate,
evaluate, and synthesize diverse sources of information; also
known as "guided discovery"
6. Capsule summariesto maintain focus and a connection to the goals
of the therapy
7. Homework assignmentsto serve as a bridge between sessions and
to ensure that the client continues to work on problems by
collecting information, testing beliefs, and trying new behaviors
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learned in previous sessions, help the client see how she slipped into old
patterns, and further reinforce the process of catching oneself in the process
of thinking negative automatic thoughts. The therapist must be prepared to
move from topic to topic while always adhering to the major themethat
how the client thinks determines how the client feels and acts, including
whether the client abuses substances.
Cognitive therapy can be quite successful as an option for brief therapy
for several other reasons (Carroll, 1996a):
It is designed to be a short-term approach suited to the resource
capabilities of many delivery systems.
It focuses on immediate problems and is structured and goal
oriented.
It is a flexible, individualized approach that can be adapted to a
wide range of clients, settings (both inpatient and outpatient),
and formats, including groups.
Cognitive-Behavioral Theory
Early behavioral theories of substance abuse were nonmediational in
nature (Donovan and Marlatt, 1993). They focused almost exclusively on
overt, observable behaviors, and it was believed that understanding the
antecedents and reinforcement contingencies was sufficient to explain
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behavior and to modify it. Over time, however, these behavioral theories
began to incorporate cognitive factors into their conceptualizations of
substance abuse disorders. These more recent models are mediational in
nature; that is, a greater role is attributed to the interaction among a variety
of individual difference variables such as beliefs, values, perceptions,
expectations, and attributional processes in mediating the development and
continuation of substance abuse disorders (Abrams and Niaura, 1987;
Mackay and Donovan, 1991; Marlatt et al., 1988; Marlatt and Donovan, 1981).
This expanded, mediational model has been described as cognitive social
learning or cognitive-behavioral theory. This theory postulates that cognitive
factors mediate all interactions between the individual, situational demands,
and the person's attempts to cope effectively.
Cognitive-behavioral theory represents the integration of principles
derived from both behavioral and cognitive theories, and it provides the basis
for a more inclusive and comprehensive approach to treating substance abuse
disorders. However, a broader range of cognitions is included in cognitivebehavioral theory than had been involved in earlier versions of cognitive
theory. These include attributions, appraisals, self-efficacy expectancies, and
substance-related effect expectancies. Each of these will be reviewed briefly
below. Common elements of brief cognitive-behavioral therapy are listed in
Figure 4-13.
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Figure 4-13
Common Elements of Brief Cognitive-Behavioral Therapies
The therapist focuses on current problems.
She establishes attainable and contracted goals.
She seeks to obtain quick results for the most pressing problems.
She relies on a variety of empirically based techniques to increase the client's
ability to handle his own problems.
Source: Adapted from Bloom, 1997; Peake et al., 1988.
Attributions
An attribution is an individual's explanation of why an event occurred.
Abramson and colleagues proposed that individuals develop attributional
styles (i.e., individual ways of explaining events in their lives that can play a
role in the development of emotional problems and dysfunctional behaviors)
(Abramson et al., 1978). The basic attributional dimensions are
internal/external, stable/unstable, and global/specific. For instance, clinically
depressed persons tend to blame themselves for adverse life events
(internal), believe that the causes of negative situations will last indefinitely
(stable), and overgeneralize the causes of discrete occurrences (global).
Healthier individuals, on the other hand, view negative events as due to
external forces (fate, luck, environment), as having isolated meaning (limited
only to specific events), and as being transient or changeable (lasting only a
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short time). Figure 4-14 lists and further defines the three dimensions of
attribution that make up an "attributional style."
Attributional styles play a major role in the cognitive-behavioral theory
of substance abuse disorders (Davies, 1992; Marlatt and Gordon, 1985). The
nature of substance abusers' attributional styles is thought to have
considerable bearing on their perception of their substance abuse problem
and their approach to recovery. An alcohol-dependent client, for instance,
may believe that he drank because he was weak (an internal attribution) or
because he was surrounded by people encouraging him to have a beer (an
external attribution). He may believe that his failure to maintain abstinence
shows that he is a weak person who can never succeed at anything (a global
attribution) or that a drinking episode does not represent a general
weakness, but was instead due to the specific circumstances of the moment (a
specific attribution). He may believe that the cause of his slip is something he
cannot change (a stable attribution) or that the next time, he will catch
himself and exert better coping responses (an unstable attribution). Whereas
the internal, global, and stable attribution for the use of alcohol is likely to
lead to feelings of hopelessness and a return to drinking, the external, specific,
unstable attribution is likely to lead to greater efforts to cope with similar
situations in the future.
Figure 4-14
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Attributional Styles
Internal/External:
Stable/Unstable:
Global/Specific:
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state increase the likelihood that the initial lapse will develop into a fullblown relapse. Research with individuals dependent on alcohol, marijuana,
opiates, and other illicit drugs, provides empirical support for the
attributional style hypothesized to mediate the AVE (Birke et al., 1990;
Bradley et al., 1992; Reich and Gutierres, 1987; Stephens et al., 1994; Walton
et al., 1994).
Cognitive Appraisal
For the cognitive-behavioral therapist, an individual's appraisal of
stressful situations and his ability to cope with the demands of these
situations are important influences on the initiation and maintenance of
substance abuse, as well as relapse after cessation of use (Hawkins, 1992;
Marlatt and Gordon, 1985; Shiftman, 1987,1989; Wills and Hirky, 1996).
Folkman and Lazarus described two different levels of cognitive
appraisal (Folkman and Lazarus, 1988,1991). The first level is a primary
appraisal. This represents the individual's perception of a situation and an
estimation of the potential level of stress, personal challenge, or threat
involved with the situation. Secondary appraisal represents the individual's
evaluation of her ability to meet the challenges and demands specific to the
situation. This secondary appraisal, which will be influenced by the extent,
nature, and availability of the individual's coping skills, further mediates the
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Coping behaviors
In substance use-related situations, coping "refers to what an individual
does or thinks in a relapse crisis situation so as to handle the risk for renewed
substance use" (Moser and Annis, 1996, p. 1101). Cognitive-behavioral theory
posits that substance users are deficient in their ability to cope with
interpersonal, social, emotional, and personal problems. In the absence of
these skills, such problems are viewed as threatening, stressful, and
potentially unsolvable. Based on the individual's observation of both family
members' and peers' responses to similar situations and from their own
initial experimental use of alcohol or drugs, the individual uses substances as
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a means of trying to deal with these problems and the emotional reactions
they create. From this perspective, substance abuse is viewed as a learned
behavior having functional utility for the individualthe individual uses
substances in response to problematic situations as an attempt to cope in the
absence of more appropriate behavioral, cognitive, and emotional coping
skills.
A number of dimensions are involved in the coping process as it relates
to substance abuse (Donovan, 1996; Hawkins, 1992; Lazarus, 1993; Shiftman,
1987; Wills and Hirky, 1996). The first is the general domain in which the
coping response occurs. Coping responses can occur within the affective,
behavioral, and cognitive domains. Litman identified a number of behavioral
and cognitive strategies that are protective against relapse (Litman, 1986).
There are two behavioral classes of coping behavior:
(1) basic avoidance of situations that have been previously associated
with substance abuse and
(2) seeking social support when confronted with the temptation to
drink or use drugs.
The cognitive domain also includes two general categories of coping: (1)
negative thinking, or thinking about all the negative consequences that have
resulted from substance abuse and a desire to no longer experience these,
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and (2) positive thinking, or thinking about all the benefits that are accrued
by being clean and sober and not wanting to lose these. Litman suggests that
these coping strategies operate in a somewhat sequential manner (Litman,
1986). Initially, when clients are attempting to initiate and stabilize
abstinence from substances, they appear to rely more heavily on the
behavioral strategies. As the period of abstinence increases, there appears to
be a transition from predominantly behavioral strategies toward a greater
reliance on cognitive methods of coping.
Coping strategies have a number of other dimensions. They can be
emotion focused, problem focused, or avoidant. A distinction is also made
between those that are general coping strategies and those that are expressly
attempting to cope with urges, craving, and temptation to use in settings
associated with past substance abuse. Another important dimension of coping
strategies is the stage at which they are used in response to a potentially
difficult substance-related situation (Shiftman, 1989). Anticipatory coping is
employed as one anticipates and attempts to plan how to deal with upcoming
situations. They take the form of "What can I do if...." There are also coping
strategies that are employed in the moment that one is having to deal with
the difficult substance-related situations. They take the form of "What can I
do now....'' Finally, there are restorative coping strategies that can be
employed if one fails to cope and finds himself using in the situation. These
take the form of "What can I do now that I've..." It is these restorative coping
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Self-Efficacy Expectancies
The apparent lack of coping skills among substance users is an
important contributor to another key construct in cognitive-behavioral
approaches, namely self-efficacy expectancies (Bandura, 1977). These
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Figure 4-15
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High-Risk Situations
Over time, with repeated exposure, aspects of a situational context (e.g.,
the people, places, feelings, activities) can come to serve as conditioned cues
that can elicit a strong craving or desire to use. To the extent that substance
abuse allows the individual to avoid or escape such problem situations or
their resultant emotional reactions, the use of substances will be reinforced
through operant learning. Thus the likelihood is increased that substances
will be abused and will come to be relied on in the future when the individual
encounters similar situations.
Marlatt and colleagues have characterized a number of situations in
which substances are abused (Chaney et al., 1982; Cummings and Gordon,
1980; Marlatt and Gordon, 1980,1985). While the original taxonomy of these
situations focused on settings in which relapse occurred following a period of
abstinence from a substance, the settings appear to represent situations in
which substance use in general will be more likely to occur (Annis and Davis,
1988a; Marlatt, 1996). The situations as originally categorized are found in
Figure 4-16.
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conflict were the most important risk factors. Again, it is the individual's
appraisal of such situations, in terms of its threat to maintaining abstinence
relative to their available coping abilities, that determines the situational risk
for the individual (Myers et al., 1996).
Figure 4-16
Taxonomy of High-Risk Situations Based on Marlatt's Original Categorization
System
Intrapersonal-Environmental Determinants
Coping with negative emotional states
Coping with frustration and anger
Coping with other negative emotional states (e.g., fear, anxiety, tension, depression,
loneliness, sadness, boredom, grief, loss, guilt)
Coping with negative physical/physiological states
Coping with physical states associated with prior substance use (e.g., withdrawal
distress)
Coping with other negative physical states (e.g., pain, illness, injury, fatigue)
Enhancement of positive emotional states (e.g., using substances to enhance pleasure,
for celebration)
Testing personal control (e.g., using to test "willpower" to see if treatment worked, to
see if one can drink or use in a moderate way)
Giving in to temptations or urges
In the presence of substance-related cues
In the absence of substance-related cues
Interpersonal Determinants
Coping with interpersonal conflict
Coping with frustration and anger
Coping with other interpersonal conflict
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Figure 4-17.
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Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) derives, in part, from both
behavioral and cognitive theories. While sharing a number of procedures in
common, CBT is also distinct in many ways from these other therapies
(Carroll, 1998). In comparison to cognitive therapy, CBT places less emphasis
on identifying, understanding, and changing underlying beliefs about the self
and the self in relationship to substance abuse. It focuses instead on learning
and practicing a variety of coping skills, only some of which are cognitive. A
greater emphasis is also placed on using behavioral coping strategies,
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especially early in therapy. CBT tries to change what the client both does and
thinks.
In comparison to behavioral treatments such as the community
reinforcement approach, CBT focuses more on cognitions, beliefs, and
expectancies. Also, CBT generally does not incorporate contingency
management approaches such as the use of vouchers to reinforce desired
behaviors. CBT is usually confined to the treatment session (although
therapists often give homework to clients to be completed outside the
therapy session), whereas the community reinforcement approach stresses
the importance of incorporating interventions into real world settings and
taking advantage of community resources. Figure 4-18 lists a number of
features thought to be unique to cognitive-behavioral interventions.
Figure 4-18
Essential and Unique Elements of Cognitive-Behavioral Interventions
The key ingredients that distinguish CBT from other some other therapies and that must be
included in a CBT treatment include the following:
A functional analysis of substance abuse
Individualized training in recognizing and coping with craving, managing thoughts
about substance abuse, problem-solving, planning for emergencies, recognizing
seemingly irrelevant decisions, and using refusal skills
An examination of the client's cognitive processes related to substance abuse
The identification and debriefing of past and future high-risk situations
The encouragement and review of extra-session implementation of skills
Practice of skills within sessions
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CBT uses learning processes to help individuals reduce their drug use. It
works by helping clients recognize the situations in which they are likely to
use, find ways of avoiding those situations, and cope more effectively with
situations, feelings, and behaviors related to their substance abuse (Carroll,
1998). To achieve these therapeutic goals, cognitive-behavioral therapies
incorporate three core elements: (1) functional analysis, (2) coping skills
training, and (3) relapse prevention (Rotgers, 1996).
Functional Analysis
Behavioral, cognitive, and cognitive-behavioral treatments all rely
heavily on an awareness of the antecedents and consequences of substance
abuse. In all of these therapeutic approaches, the client and therapist typically
begin therapy by conducting a thorough functional analysis of substance
abuse behavior (Carroll, 1998; Monti et al., 1994; Rotgers, 1996). This
analysis attempts to identify the antecedents and consequences of substance
abuse behavior, which serve as triggering and maintaining factors.
Antecedents of use can come from emotional, social, cognitive, situational/
environmental, and physiological domains (Miller and Mastria, 1977). The
functional analysis should also focus on the number, range, and effectiveness
of the individual's coping skills. While a major emphasis in cognitive-
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assist the therapist in the assessment and functional analysis. The therapist
should try to evaluate the number and type of high-risk situations, the
temptation to use in these situations, confidence that one will not use in highrisk situations, substance abuse-related self-efficacy, frequency and
effectiveness of coping, and substance-specific effect expectancies. More
detailed information on the assessment process in cognitive-behavioral
approaches to substance abuse and its treatment is available in a number of
sources (Donovan, 1998; Donovan and Marlatt, 1988; Monti et al., 1994;
Sobell et al., 1988; and Sobell et al., 1994). For a review of assessment tools
that can be used in developing a functional analysis see TIP 35, Enhancing
Motivation for Change in Substance Abuse Treatment (CSAT, 1999c).
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inhibited from using them. Whatever the origin of the deficits, a primary goal
of CBT is to help the individual develop and employ coping skills that
effectively deal with the demands of high-risk situations without having to
resort to substances as an alternative response.
A number of published treatment manuals are available to guide skills
training with substance users (Carroll, 1998; Kadden et al., 1992; Monti et al.,
1989). These manuals provide a session-by-session overview of the
intervention. The material covered in these interventions can be categorized
into a number of broad classes. The skills to be taught are either specific to
substance abuse (e.g., coping with craving, refusing an offer of alcohol or
drugs) or apply to more general interpersonal and emotional areas (e.g.,
communication skills, coping with anger or depression). They are either
cognitive or behavioral in nature. Some might be viewed as essential and
would be expected to be used for all clients, while others would be viewed as
more elective in nature and would be selected for a particular individual
based on the functional analysis. The ability to individually tailor the skills
training to the client's needs represents one of the strengths of CBT.
Figure 4-19 presents a list of session topics (Monti et al., 1989) which
served as the foundation for the CBT delivered in Project MATCH (Matching
Alcohol Treatment to Client Heterogeneity Project) (Kadden et al., 1992), a
large multisite study of treatment matching funded by the National Institute
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on Alcohol Abuse and Alcoholism (NIAAA). While the topics used in this
particular example were developed for use with clients with alcohol abuse
disorders, they are easily adapted to the needs of clients who are abusing
other substances.
Figure 4-19
Intrapersonal and Interpersonal Skills Training Elements
Intrapersonal Skills
Interpersonal Skills
Problem-solving
Starting conversations
Decision-making
Assertiveness training
Managing anger
Refusing requests
Communicating emotions
Communicating in intimate
relationships
Giving criticism
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Receiving criticism
Figure 4-20
Assertiveness Training
The client is encouraged to disclose and express emotions and needs, to stand up
for his rights, to do what is best for himself, and to express negative emotions
constructively. This is useful for clients with substance abuse disorders because
being unable to express their emotions and needs may lead to relapse As a client
becomes more assertive, he will be better able to control his impulsive behavior
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Relapse Prevention
The third core element of CBT is relapse prevention. While there are a
number of different models of relapse (Donovan and Chaney, 1985), the two
best articulated within the cognitive-behavioral model are those presented by
Annis and Davis and Marlatt and Gordon (Annis and Davis, 1988b; Marlatt
and Gordon, 1985). Relapse prevention approaches rely heavily on functional
analyses, identification of high-risk relapse situations, and coping skills
training, but also incorporate additional features. These approaches attempt
to deal directly with a number of the cognitions involved in the relapse
process and focus on helping the individual gain a more positive self-efficacy.
Although self-efficacy is related to the availability of coping skills and
would be expected to increase as the client learns new skills, this does not
always occur spontaneously. It is often necessary to help the client change the
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were used to make the students aware that some of their alcohol-related
expectancies were false. For example, the heavy-drinking college students
were told that the beverages they were drinking contained alcohol, but they
were actually given nonalcoholic drinks, disguised to look, smell, and even
taste like alcohol. They then engaged in group party games, in which most
displayed the uninhibited behavior that is associated with alcohol
intoxication. Later, when they were told that their beverages were actually
placebos, they were surprised. Group discussion and other information on
placebo effects altered their perceptions of the positive effects of alcohol. A
significant decrease in alcohol consumption was noted in this group after the
intervention, compared to a control group that received conventional
information on the effects of alcohol. Challenging social beliefs about the
effects of a substance may alter its use.
Another way to use substance expectancy information in therapy is to
have the client consider both the positive and negative effects of the
substance. Many clients have automatic scripts like "I'll feel more relaxed if I
drink" without considering other scenarios, like: "I'll drink too much. I'll have
a fight with my girlfriend, and then I'll sleep in and not go to class." The
therapist helps the client acknowledge that the other consequences exist and
are not being attended to. It is possible to use a decisional balance procedure
in this process, wherein the client is asked to list all the positive and negative
things associated with drug use. By acknowledging the substance's positive
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effects, the therapist gains credibility and reduces resistance from the client.
The client can more easily acknowledge the negative aspects of substance
abuse and make those beliefs more salient. This technique is a mainstay of
motivation enhancement therapies that are largely cognitive in nature (Miller
and Rollnick, 1991). (TIP 35, Enhancing Motivation for Change in Substance
Abuse Treatment [CSAT, 1999c], gives more detailed information on these
approaches.)
Relapse prevention also stresses the importance of preparing for the
possibility of a relapse and planning ways to avoid it or, failing this, stop the
process quickly and with minimal harm when it does occur. Clients are
sometimes apprehensive about talking so directly about the possibility of
relapse. The therapist can help dispel these concerns by using an analogy of
fire drills. Having a drill and being prepared for a fire does not necessarily
mean that a fire will occur. However, if one does, it will be possible to get out
of the situation without getting burned. It is helpful to have very concrete
emergency plans, including the phone numbers of individuals supportive of
the client's recovery process. Including family members in the planning
process is important because they are often better able than the client to see
the warning signs of an impending relapse.
Relapse prevention also stresses the development of a more balanced
and healthier lifestyle. Marlatt and Gordon posit that one source of possible
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relapse risk has to do with the degree of stress or daily hassles that the client
experiences (Marlatt and Gordon, 1985). They suggest that when the
demands and obligations a client feels ("shoulds") outweigh the pleasures the
individual can engage in ("wants"), then his life is out of balance. This often
results in feelings of deprivation and resentment. In response to these
feelings, the individual could begin making decisions that gradually lead
toward possible relapse. The goal is to help the individual find a better
balance, increasing involvement in pleasant and rewarding activities while
reducing the level and sources of stress.
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Client: Well, I just can't stop using. Even when I've gone through treatment in the
past, I end up using in no time. When I look at my track record, I don't see
much of a future.
Therapist: I wouldn't give up hope yet. We'll work together to help you get a better
look at your cocaine use, some of the things that trigger it, and some of the
benefits you think you get from it. Sometimes by looking at your use from a
different perspective, you can help put it into context and things don't seem
so hopeless. Now why don't you tell me about how you slipped and started
using after your last time in treatment. What was going on in your life?
What were you feeling? What were you thinking about yourself and your
life?
Client: Well, when I got out I still had some doubts about whether I would make it
or not. I mean I felt better about myself, but there was still a lot of crap
going on in my life. I had bills to pay. My relationship was falling apart. I was
still being hassled by my probation officer. I was feeling kind of
overwhelmed. Here I thought I would walk out of there a new man, but I
walked out with all the same problems.
Therapist: Was there any time after treatmentwhen you felt you could handle all
the problems facing you?
Client: Well, for a while, then I started to feel depressed. I mean you go through
treatment, and this stuff shouldn't be happening.
Therapist: What did you try to do to deal with it all?
Client: At first I thought I would get myself organized and get a plan. But it didn't
work. As much as I tried, I couldn't figure out a way to put all this stuff in its
place and handle it. So I just threw up my hands and said, "Screw it!" I felt
like the best thing to do was to pull the blankets over my head and hope that
it would all blow over.
Therapist: So, did it blow over?
Client: No. Things just kept getting worse. I couldn't pay my bills. My relationship
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In this case study, it is clear that the client has a low sense of selfefficacy predicated in part by his past treatment failures and his inability to
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form of treatment (see Figure 4-21). However, even though these criteria
were derived from cocaine users, they appear to be applicable to clients using
other substances.
Figure 4-21
Types of Clients for Whom Outpatient CBT Is Generally Not Appropriate
Those who have psychotic or bipolar disorders and are not stabilized on medication
Those who have no stable living arrangements
Those who are not medically stable (as assessed by a pretreatment physical
examination)
Those who have concurrent substance dependence disorders, with the possible
exception of alcohol or marijuana dependence
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5
Brief Strategic/Interactional Therapies
Strategic/interactional therapies attempt to identify the client's
strengths and actively create personal and environmental situations where
success can be achieved. In these therapies, the focus is on the individual's
strengths rather than on pathology, the relationship to the therapist is
essential, and interventions are based on client self-determination with the
community serving as a resource rather than an obstacle. This model has
been widely used and successfully tested on persons with serious and
persistent mental illnesses (Rapp and Wintersteen, 1989; Saleebey, 1996;
Solomon, 1992). It has also been used with persons who have problems
related to substance abuse (Juhnke and Coker, 1997; Miller and Berg, 1991;
Ratner and Yandoli, 1996; Watzlawick et al., 1967). Although the research to
date on these therapies (using nonexperimental designs) has not focused
exclusively on substance abuse disorders, the use of these therapies in
treating substance abuse disorders is growing.
Many different theoretical approaches have strategic or interactional
roots. They can be distinguished from each other primarily by the different
emphasis and value they place on components of the change process.
Therapists rarely follow a single theoretical approach strictly; therapists
today influence and learn from each other, incorporating what they find
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and practices, most of the work currently being done on substance abuse
treatment uses a solution-focused approach. Solution-focused therapy is
always brief, and to date there has not been a great deal of research
comparing it to other models.
Research by Iguchi and colleagues supports some of the theoretical
claims made by solution-focused therapists (Iguchi et al., 1997). The solutionfocused therapist believes that helping clients with substance abuse disorders
to address any life problems they find significant will help them to reduce
their substance use. What is important is finding a solution to the problems
the client identifies as significant, then reinforcing the client's success in
solving those problems. This procedure helps the client to recognize her own
ability to solve her problems. The study by Iguchi and colleagues compared
the role of urine testing, traditional substance abuse counseling services, and
the reinforcement of nonsubstance-use-related positive life changes and
found that the latter resulted in the most significant reduction in substance
use even after reinforcement contingencies ended.
The solution-focused therapy model has been used to respond to a
range of problems and complaints. Researchers Berg and Miller were the first
to apply the model specifically to the treatment of alcohol-related problems,
but others also have used these techniques for treating substance abuse
disorders (Berg, 1995; Berg and Miller, 1992; Berg and Reuss, 1998; Ratner
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deliberate exceptions and random exceptions (see Figure 5-1 for definitions).
The more deliberate the behavior on the part of the client, the easier it will be
for her to repeat it. But even substance-free periods that seemed to result
from outside influences (i.e., random exceptions) can be used to help the
client realize her own ability to stay sober.
Figure 5-1
Deliberate and Random Exceptions to Substance Abuse Behaviors
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her problems. By focusing on those areas the client considers significant (e.g.,
relationships, work, financial security), the therapist assists the client in
understanding how her substance abuse affects those significant areas of
concern. The therapist helps the client solve those significant problems while
strongly reinforcing the client's success. After the initial session, the therapist
keeps the client focused on how her situation is improving by asking, "What's
better this time?"
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points in maintaining sobriety. For example, the therapist can help the client
identify the "payoff" for not attending the meeting and the key players in the
system that maintains the client's substance abuse. Even a client who feels he
is powerless over substance abuse without the help of a higher power can
recognize he has some control over the choices that lead to substance abuse.
Some therapists familiar with 12-Step programs may be concerned that
the strategic/interactional approach is opposed to viewing addiction as a
disease. The focus on empowering the client may seem incompatible with the
first step (i.e., "we admitted we were powerless over..."). However, the key to
therapeutic success with this approach is the ability to work within a client's
frame of reference. Therapists can acknowledge that addiction is a disease
but still use the strategic/interactional approach to enhance clients' coping
skills and help them to control the use-related behaviors that clients may
believe are random and spontaneous. Strategic therapists who do not accept a
disease model may tell a client, "You have a disorder of the pleasure centers
in your brain," and work with the client to find healthier ways to activate
those "pleasure centers."
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Her family, or her reaction to it, may have influenced her decision to begin
using or her decision to stop. Messages from the family (internalized or
actual) can also play an ongoing role in the client's choice to continue using.
One therapist treated a woman whose entire family appeared to have
alcohol-related problems and who believed that everyone drank, but at
different levels. For this client, a strategic/interactional approach helped her
become aware of new possibilities, develop social skills, and identify sober
activities. She learned to see the world as a richer place with many options.
The therapist in this case chose to be directive and showed the client the
possibilities for change that exist. To many clients who are trying to change
their behavior, it is reassuring to believe that "there is someone who knows
the way." The therapist using this strategic/interactional approach should
convey a sense of hope that bridges the chasm between what is and what
could be and support the client through the change process with respect.
The strategic/interactional approach can also help break through a
stalemate in a relationship that blocks healing, particularly if there has been a
power struggle that has left both parties exhausted and with an apparently
restricted range of options. In a power struggle, each person says she is right
and the other is wrong; one of them must give in. When the
strategic/interactional approach is applied to power struggles it can help to
"open up the system," working to change the clients' perceptions of each
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other and their relationship and enable them to see a broad range of options.
Both parties are assisted in seeing themselves as strong, capable, and in
control. Because the substance abuser typically feels helpless, inadequate,
and condescended toward, the therapist often has to rebalance the power
structure to promote more effective interactions.
For example, in a situation where one partner pushes the other to stop
drinking, the partner who has been drinking may feel controlled and
demeaned and therefore may withdraw in a passive manner or react with an
explosive temper. He then gets drunk to further express his anger or to get
even. The partners' respective behaviors maintain the problem. The therapist
works to help each partner perceive the other more positively. As this is
accomplished, each person becomes more receptive to new solutions. The
therapist then helps the partners identify specific changes they can make,
thus dismantling the old system and laying the foundation for a new one that
can support different behavioral choices.
The strategic/interactional approach is also an appropriate way to
address a client's fear of change. Often, clients feel that "something worse"
may happen when they quit using. In the Eriksonian model, a therapist might
ask the client to project herself into the future and describe what it will be
like when the changes just discussed have been made, or talk about a "future
self" who has resolved current problems and for whom current fears are no
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longer an issue. Such strategies are useful in confronting common fears and
helping clients see beyond them.
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clients who have serious mental illnesses (Saleebey, 1996; Solomon, 1992).
Case Study
Figure 5-2 presents a portion of a dialog between a counselor and a
client, a 45-year-old real estate agent who was treated 4 years ago in an
inpatient treatment program and thereafter attended a 12-Step group to help
him stop his polysubstance abuse (cocaine and alcohol). After experiencing 3
clean and sober years, he began to use again. The client started gambling,
then using cocaine and alcohol while gambling. His real estate license is now
in jeopardy because of customer complaints and reports to the State
Licensing Board. He was recently convicted for a second time for driving
under the influence (DUI), and his wife and family moved out. The client tells
the therapist that his renewed abuse of substances was the result of the
gambling. Unlike the negative feedback from family, colleagues, and other
professionals, the therapist, using strategic/interactional approaches, praises
the client for coming back to treatment: "Look at what you have done! You're
in this chair instead of still out there." The therapist assures the client that
relapse is part of the recovery process and suggests that the experience can
be seen as educational. In contrast to emphasizing the client's failure, the
therapist sends the message, "You're a survivor, not a victim." The therapist
affirms the client's ability to stay sober and begins to seek ways to emphasize
and draw on the client's strengths. The therapist seeks to understand the
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events that led up to renewed use but also searches for the behaviors that
previously helped the client stay abstinent for 3 years.
Figure 5-2
Strategic/Interactional Therapy in Practice: A Case Study
Conversation
Observations
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on the cocaine.
Therapist: How did that
cocaine work for
you?
Client: I was excited. I felt
really powerful.
Therapist: What went
wrong? What led you
start using alcohol,
too?
Client: I got scared. I was
up for 3 days. The
alcohol helped me
come down and
sleep.
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me down before.
Therapist: I hear that you
realized something
needed to be done,
and you knew you
needed something to
slow you down, and
you took action.
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Therapist: It sounds to me
like you have
incredible inner
strength. What keeps
you going?
Client: I don't want to die.
Therapist: It sounds like
you have a very
strong, competent
side that wants the
best for you and
wants to live. Let's
use that competent
part of you to get
back on track and
rebuild your life.
What do you think?
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Therapist: That's
interesting. Despite
the fact that you feel
empty, you can still
function. I think
there is something
internally powerful
in you that has not
come out. For some
reason, it has been
suppressed. My
guess is that the
boredom comes
when you suppress
that side of you.
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effective.
Strategic/Interactional Therapies
The primary strength of strategic/interactional approaches is that they
shift the focus from the client's weaknesses to the client's strengths. The
therapist's task is to help the client identify, recognize, and use these
strengths to make the changes the client sees as beneficial.
Strategic/interactional therapies are based on three primary theoretical
assumptions:
1. These therapies take a constructivist view of reality. They assert that
reality is determined by individual perceptions, which are
influenced by cultural, sociopolitical, and psychological factors.
2. These therapies stress the importance of attribution of meaning.
According to this theoretical approach, it is the meaning we
attribute to situations that determines whether a problem exists.
In this model, an important therapeutic goal is to understand the
meanings that clients attribute to eventsoften referred to as the
client's "frame of reference"and to use this knowledge to
promote constructive change. This can involve helping clients to
construct a different meaning that is more useful to them in the
recovery process.
3. These therapies focus on human interactions and the problems that
evolve from ineffective ways of coping with situations. There is
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way, the therapist can make more progress by working within that frame of
reference to accomplish strategic objectives. The therapist might ask, "If your
boss is driving you to drink, how does that happen and what can you do about
that?" The therapist implies that the client must be more effective in
interactions with his boss, and this becomes a treatment issue. By working
within the client's frame of reference, the therapist can define what the client
might do to change key interactions that contribute to substance abuse,
without buying into the premise that it is only his boss' behavior that must
change.
Initial Session
The first question that a therapist using a strategic/interactional
approach should ask is, "Why are you here?" The first session should be spent
trying to understand the client's problem. However, different models
(discussed later in this section) use different tactics to explore the nature of
the problem, as follows:
The therapist using Eriksonian therapy seeks to define the
client's problem in the client's terms and probe the way she
understands the problem (i.e., the "frame"). Compared to
other strategic interactional models, the Eriksonian approach
moves more quickly to action, seeks to effect change more
quickly, and places greater emphasis on the unconscious
processes underlying change.
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Later Sessions
Once the therapist has encouraged a person with a substance abuse
disorder to take further steps toward change, the subsequent sessions will
focus on identifying and supporting additional steps in the same direction.
The following are examples of techniques that might be used in the remaining
sessions with the client in this case study.
Set up a termination point. The therapist could ask the client to
describe the signs that things are getting better for him, or
ask, "What things will you be doing differently?"
The therapist could continue to develop effective strategies and
increase their use. She could use affirmations, continue to use
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"helper" role in some area of his life. This shifts the focus
further from his view of himself as a helpless, incompetent
addict to a strong, caring, competent person who can help
others. This client's participation in AA might give him the
opportunity to help others in this manner.
As the end of the therapeutic process nears, the therapist helps the
client prepare for the future. Following are suggestions for how the therapist
can do this.
Prepare the client to maintain positive change through difficult
times. It is useful to convey the idea that the learning curve is
never a straight slope; rather, it is a curvy line, with peaks and
dips. There will be slips. It is unrealistic to expect perfection.
Life will continuously have "ups and downs"the goal is not
to make things even but to cope effectively with these ups and
downs.
Identify what the potential next stressors and challenges will be.
Work through the following question with the client: "Given
what we've learned, how would you cope with the next
stressor/challenge?"
Devote some time to preparing the client for changes to the
environment. For example, how will significant people in his
life react to his change in behavior?
Ask the client to look into the future at the end of the treatment
period and tell the therapist where he intends to be at a certain
time (this is an Eriksonian approach). The therapist could ask
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for a specific date when the client expects to get there and ask
the client to call the therapist on that date. This process sets
up an expectation of progress and accountability.
Ericksonian Therapy
All forms of strategic/interactional therapies have their roots in the
work of Milton Erikson, an innovative psychotherapist who was one of the
first theorists to suggest the importance of working within the client's
"frame." With his unique use of hypnotherapy he fostered rapid changes in
his clients, often in an indirect fashion. Through this work he came to
emphasize unconscious factors in change and the importance of indirect ways
to shift meanings and behavior. His approach is active, building on clients'
resources to help them attain their goals. The therapist and client cooperate
in building an awareness of the client's experience and an understanding of its
meaning. Together, they build a context for change.
Erikson's interventions emphasize the following:
Suggestion as a means of bypassing an impasse, reframing the
problem, and taking a first step toward solving it
Metaphor as indirect interventiona way to help the client
retrieve resources and create a unique response that builds a
bridge for learning; the therapist uses the client's metaphors
(e.g., if the client sees recovery as a road, then the therapist
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times when you can see pieces of the miracle and the times
when you can see only the problem?").
Use scaling to determine how well the client thinks things are
going, how willing she is to work toward the "miracle," her
confidence in her ability to change, and the steps needed to
improve the situation from one rating on the scale to the next
highest.
Try taking "time-outs" and suggest to the client "While I step out,
I want you to think of the next smallest step you could take
that would bring you to the next number on the scale."
Affirm client competencies (e.g., tell the client, "I am impressed
you are sitting in that chair again after what you just went
through"). Many of these clients have never had this success
acknowledged before.
Suggest tasks that the client can perform to improve her
situation (e.g., ask her to do something achievable that would
provide useful information or move her closer to the
"miracle" she has chosen).
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situation, using the same ineffective approach each time. A client's belief
system can cause him to develop ineffective approaches to problems that
result in maintaining or even exacerbating the difficulty. The more the client
uses an ineffective solution to solve a problem, the more the problem is
reinforced and maintained. The solution lies in helping the client change his
perception of the problem, then either modify the attempted solution so it has
a greater chance of success or devise a more effective solution. These new
solutions (generally referred to as second order change) work best if they are
sufficiently different from the ineffective, previously attempted solutions.
In each session, practitioners using the MRI brief therapy model should
try to do the following:
Define the problem in behavioral terms. For example, a client may
say, "I feel compelled to join the others at work in drinking,
although as a result I have such a 'short fuse' that I get in
fights and even hurt my wife."
Determine how the client understands the problem. What is her
"frame of reference" or "position"? It is important to
understand how the client views her problem and what
attitudes she has toward the problem. For example, a client
might insist that her substance abuse is the result of
pressures at work. However, the therapist notes that she
began using after the death of her spouse and therefore
hypothesizes that the substance abuse is related to her deep
grief. The challenge for the therapist is to work with the
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the wife's drinking serves to stabilize the family and avoid the real issues of
the wife's anger and the husband's infidelity. The therapist would work with
the wife to express her anger in a way other than drinking, and define the
issue as one of trust in the marriage.
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6
Brief Humanistic and Existential Therapies
Humanistic and existential psychotherapies use a wide range of
approaches to case conceptualization, therapeutic goals, intervention
strategies, and research methodologies. They are united by an emphasis on
understanding human experience and a focus on the client rather than the
symptom. Psychological problems (including substance abuse disorders) are
viewed as the result of inhibited ability to make authentic, meaningful, and
self-directed choices about how to live. Consequently, interventions are
aimed at increasing client self-awareness and self-understanding.
Whereas the key words for humanistic therapy are acceptance and
growth, the major themes of existential therapy are client responsibility and
freedom. This chapter broadly defines some of the major concepts of these
two therapeutic approaches and describes how they can be applied to brief
therapy in the treatment of substance abuse disorders. A short case illustrates
how each theory would approach the client's issues. Many of the
characteristics of these therapies have been incorporated into other
therapeutic approaches such as narrative therapy.
Humanistic and existential approaches share a belief that people have
the capacity for self-awareness and choice. However, the two schools come to
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Everyone suffers losses (e.g., friends die, relationships end), and these losses
cause anxiety because they are reminders of human limitations and inevitable
death. The existential therapist recognizes that human influence is shaped by
biology, culture, and luck. Existential therapy assumes the belief that people's
problems come from not exercising choice and judgment enoughor well
enoughto forge meaning in their lives, and that each individual is
responsible for making meaning out of life. Outside forces, however, may
contribute to the individual's limited ability to exercise choice and live a
meaningful life. For the existential therapist, life is much more of a
confrontation with negative internal forces than it is for the humanistic
therapist.
In general, brief therapy demands the rapid formation of a therapeutic
alliance compared with long-term treatment modalities. These therapies
address factors shaping substance abuse disorders, such as lack of meaning in
one's life, fear of death or failure, alienation from others, and spiritual
emptiness. Humanistic and existential therapies penetrate at a deeper level to
issues related to substance abuse disorders, often serving as a catalyst for
seeking alternatives to substances to fill the void the client is experiencing.
The counselor's empathy and acceptance, as well as the insight gained by the
client, contribute to the client's recovery by providing opportunities for her to
make new existential choices, beginning with an informed decision to use or
abstain from substances. These therapies can add for the client a dimension
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Essential Skills
By their very nature, these models do not rely on a comprehensive set of
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Initial Session
The opening session is extremely important in brief therapy for building
an alliance, developing therapeutic rapport, and creating a climate of mutual
respect. Although the approaches discussed in this chapter have different
ways of addressing the client's problems, the opening session should attempt
the following:
Start to develop the alliance
Emphasize the client's freedom of choice and potential for
meaningful change
Articulate expectations and goals of therapy (how goals are to be
reached)
Developing the alliance can be undertaken through reflective listening,
demonstrating respect, honesty, and openness; eliciting trust and confidence;
and applying other principles that emerge from these therapies. The
therapist's authentic manner of encountering the client can set the tone for an
honest, collaborative therapeutic relationship. Emphasizing freedom of choice
and potential for meaningful change may be deepened by a focus on the
current decision (however it has been reached) to participate in the opening
session. Expectations and goals can be articulated through strategic questions
or comments like, "What might be accomplished in treatment that would help
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you live better" or "You now face the choice of how to participate in your own
substance abuse recovery."
Because of time constraints inherent in approaches to brief substance
abuse treatment, the early phase of therapy is crucial. Unless the therapist
succeeds in engaging the client during this early phase, the treatment is likely
to be less effective. "Engaging" includes helping the client increase motivation
for other aspects of substance abuse treatment such as group therapy.
Moreover, the patterns of interaction established during the early phase tend
to persist throughout therapy. The degree of motivation that the client feels
after the first session is determined largely by the degree of significance
experienced during the initial therapeutic encounter. A negative experience
may keep a highly motivated client from coming back, whereas a positive
experience may induce a poorly motivated client to recognize the potential
for treatment to be helpful.
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Research Orientation
The predominant research strategy or methodology in social science is
rooted in the natural science or rational-empirical perspective. Such
approaches generally attempt to identify and demonstrate causal
relationships by isolating specific variables while controlling for other
variables such as personal differences among therapists as well as clients. For
example, variations in behavior or outcomes are often quantified, measured,
and subjected to statistical procedures in order to isolate the researcher from
the data and ensure objectivity. Such strategies are particularly useful for
investigating observable phenomena like behavior. Traditional approaches to
understanding human experience and meaning, however, have been criticized
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throughout the therapeutic relationship. Placing wisdom with the client may
be useful in later stages of treatment, but a client who is currently using or
recently stopped (within the last 30 days) may not be able to make
reasonable judgments about his well-being or future.
Each therapy type discussed below is distinguished from the others by
how it would respond to the case study presented in Figure 6-1.
Figure 6-1
A Case Study
This case study will be referred to throughout this chapter. It will provide an example to which
each type of humanistic or existential therapy will be applied.
Sandra is a 38-year-old African-American woman who has abused a number of
substances, including cocaine, heroine, alcohol, and marijuana over the past 15
years. She left high school and was a prostitute for 5 years. Later she found a job
as a sales clerk at a home furnishings store. Sandra had two children in her early
twenties, a daughter who is now 15, and a son, aged 18. Because of her substance
abuse problems, they live with other relatives who agreed to raise them. Sandra
has been in treatment repeatedly and has remained substance free for the last 5
years, with several minor relapses. She has been married for 2 years, to Steve, a
carpenter; he is substance free and supports her attempts to stay away from
substances.
Last month she became symptomatic with AIDS. She has been HIV-positive for 5
years but had not developed any illnesses related to the disease. Sandra has
practiced safe sex with her husband who knew of her HIV status. Recently, after
learning from the physician at her clinic about her HIV symptoms, she began to
"shoot up," which led her back into treatment. Out of fear, she came to the
treatment center and asked to see a counselor at the clinic one day after work.
She is worried about her marriage and that her husband will be devastated by
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this news. She is afraid she is no longer strong enough to stay away from drugs
since discovering the onset of AIDS. She is also concerned about her children and
her job. Uncertain of how she will keep on living, she is also terrified of dying.
Client-Centered Therapy
Carl Rogers' client-centered therapy assumes that the client holds the
keys to recovery but notes that the therapist must offer a relationship in
which the client can openly discover and test his own reality, with genuine
understanding and acceptance from the therapist. Therapists must create
three conditions that help clients change:
1. Unconditional positive regard
2. A warm, positive, and accepting attitude that includes no evaluation
or moral judgment
3. Accurate empathy, whereby the therapist conveys an accurate
understanding of the client's world through skilled, active
listening
According to Carson, the client-centered therapist believes that
Each individual exists in a private world of experience in which
the individual is the center.
The most basic striving of an individual is toward the
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increase and her shame would decrease. She would feel supported in making
critical choices in her life and more confident to resume her recovery.
Narrative Therapy
Narrative therapy emerges from social constructivism, which assumes
that events in life are inherently ambiguous, and the ways in which people
construct meaning are largely influenced by family, culture, and society.
Narrative therapy assumes that people's lives, including their relationships,
are shaped by language and the knowledge and meaning contained in the
stories they hear and tell about their lives. Recent approaches to
understanding psychological growth have emphasized using storytelling and
mythology to enhance self-awareness (see Campbell, 1968; Feinstein and
Krippner, 1997; Middelkoop, 1989).
Parker and Horton argue that "Studies in a variety of disciplines.. .have
suggested that all cognition is inherently metaphorical" and note "the vital
role that symbolism plays in perception" (Parker and Horton, 1996, p. 83).
The authors offer the "perspective that the universe is made up of stories
rather than atoms" and suggest, "Myth and ritual are vehicles through which
the value-impregnated beliefs and ideas that we live by, and for, are
preserved and transmitted" (p. 82). From this perspective, narratives reveal a
deeper truth about the meanings of our experience than a factual account of
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The therapist may initially ask Sandra to describe some of the important
transitional moments in her life. These may include examples of loss of
innocence occurring early in her life, her experience of school, circumstances
and influences surrounding prostitution and drug use, the experience of being
supported by her husband, and internal resources that enabled her to enter
treatment and maintain sobriety. The therapist would ask questions about
expectations she felt from family, society, and herself. She may be asked
questions like, "How did addiction interfere with your attempts to be a good
mother" or "How has fear contributed to your recent relapse and feelings of
hopelessness?" Positive aspects of her story and exceptions to destructive
aspects of her narrative could be identified by asking questions like, "Were
there times that you didn't allow addiction to make choices for you?" and
"How has your ability to accept love and support from your husband helped
you?"
The focus of therapeutic dialog could then shift toward developing
alternatives to hopeless aspects of personal and cultural expectations. It
would be helpful to remind her that recent advances in medical treatments
mean that AIDS may not be the death sentence it was once thought to be.
Other important questions can help her to begin to create an alternative
story: "As you begin to understand the positive and negative influences in
your life, what qualities must you possess in order to remain sober and
develop better relationships with your husband and children?" She may need
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help replacing these stories with more positive narratives about herself. As
Sandra talks about the people and events in her life, such as her childhood
and her children, she can discover some of her feelings, as well as the
personal meaning in her story. She can experience a great deal of healing
through the therapist's feedback and questions that uncover the desires and
emotions beneath her story. A continued focus on identifying, practicing, or
even imagining changes in her story can begin the process of developing new
ways of living.
Transpersonal Therapy
Transpersonal psychology emerged as a "fourth force" in psychology in
the late 1960s and has strong roots in humanistic and existential
psychologies, Jungian analysis, the East-West dialog, and ancient wisdom
traditions. Transpersonal therapy may be thought of as a bridge between
psychological and spiritual practice.
A transpersonal approach emphasizes development of the individual
beyond, but including, the ego. It acknowledges the human spiritual quest and
recognizes the human striving for unity, ultimate truth, and profound
freedom. It cultivates intuitive ways of knowing that complement rational and
sensory modes. This approach also recognizes the potential for growth
inherent in "peak" experiences and other shifts in consciousness. Although
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and reprioritize her life. In fact, it could be argued that the best catalyst to
brief therapy may be a death sentence precisely because it has the potential
to wake up an individual. In many respects, helping the client wake from
habitual, mechanical routines that are often based on ego protection and
move toward an appreciation that the individual is not bound to or defined by
a limited ego, is the goal of transpersonal therapy. This can be seen as a
transformation of identity.
Many inspiring instances of people facing death, including death
through AIDS, have shown that emergent spirituality can change the quality
and direction of existence very quickly. For treatment, the basic sharing of
these experiences with a group of others in a similar predicament often
quickly moves the client beyond isolation and a sense of self-separateness to
connect intimately with others who understand her situation. This
community may not only bring comfort and support but also a deep sense of
communion with humanity. In this instance, breaking through the shell of
isolation may enable Sandra to begin to make new connections with her
family and with herself. A sense of interconnection, a central postulate and
experience in the wisdom traditions, may replace her perceived isolation.
Sandra may use this opportunity of facing possible death to begin to
encounter and let go of such feelings as guilt, shame, disappointment, and
anger that have kept her life less satisfying than it could be. Accessing the
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imaginal through art or dreams, for example, can provide a clear and
symbolic expression of unresolved issues. The use of rituals or rites-ofpassage inspired by the wisdom traditions can provide some catalyst for
shifting her consciousness through forgiveness and release.
The therapist may engage in a wide variety of methods (e.g., imagery,
art, or dream work, meditation, rituals), but the heart of the work is in the
simple and humane spirituality that is embodied by the therapist's loving
presence along with the therapist's openness to explore the full range of
human experience directly. For Sandra, this experience may be seen as an
opportunity for practicing love and forgiveness, moving out from behind rigid
self-separateness, facing fears, and transforming her self-definition.
Gestalt Therapy
Gestalt theory holds that the analysis of parts can never provide an
understanding of the whole. In a therapeutic setting, this approach opposes
the notion that human beings can be understood entirely through a rational,
mechanistic, scientific process. The proponents of Gestalt therapy insist that
the experiential world of a client can be understood only through that
individual's direct experience and description. Gestalt therapists seek to help
their clients gain awareness of themselves and the world. Discomfort arises
from leaving elements and experiences of the psyche incomplete primarily
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past relationships and intrapsychic conflicts that are unresolved, which Peris
calls "unfinished business'' (Peris, 1969). According to Gestalt theory
The organism should be seen as a whole (physical behavior is an
important component, as is a client's mental and emotional
life).
Being in the "here and now" (i.e., being aware of present
experience) is of primary importance.
How is more important than why (i.e., causes are not as
important as results).
The individual's inner experience is central.
For Gestalt therapists the "power is in the present" (Polster and Polster,
1973). This means that the "now" is the only place where awareness,
responsibility, and change can occur. Therefore, the process of therapy is to
help the client make contact with the present moment.
Rather than seeking detailed intellectual analysis, the Gestalt therapist
looks to create a "safe emergency" in the therapeutic encounter. Peris'
invocation to "lose your mind and come to your senses" implies that a feelinglevel, "here and now" experience is the optimal condition for therapeutic
work. This may be accomplished in a fairly short amount of time by explicitly
asking clients to pay attention (e.g., "What are you aware of now? How does
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your fear feel to you?"). The therapist may point out how the client could be
avoiding the present moment through inauthentic "games" or ways of relating
such as "talking about" feelings rather than experiencing them directly.
Clients may be asked to exaggerate certain expressions (e.g., pounding a fist)
or role-play certain internal dialogs (e.g., through an empty chair technique).
These may all serve the goal of helping clients move into the immediacy of
their experience rather than remaining distant from it through
intellectualization or substance abuse.
The term contact in Gestalt refers to meeting oneself and what is other
than oneself. Without appropriate contact and contact boundaries there is no
real meeting of the world. Instead, one remains either engulfed by the world
on one hand or, on the other hand, distant from the world and people.
Substance abuse interrupts the flow of what Peris called "organismic
self-regulation." The result is that individuals do not achieve satisfaction of
their needs and can remain unaware of what their needs are. The substance
abuser may distort or thwart the natural cycle at any of the following points:
Experiencing the need
Mobilization of energy
Contact
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Satisfaction
Withdrawal
Rest
Treatment involves bringing awareness to each of these dimensions and
the client's strategies of avoidance.
Substance abuse may also be understood as "introjection" in which the
client attempts to "swallow whole" or "drink in" his environment without
contact and discrimination. This type of client bypasses and blocks other
experiences that might enable contact and the development of discrimination.
Peris maintains that such a client seeks immediate confluence without
preparatory contact. This pattern of interaction extends to other relationships
(besides the substance) as well.
In order for this work to proceed, the therapist must maintain a finetuned, present-moment immediacy, even serving as a "resonance chamber"
(Polster and Polster, 1973) for the client's experience. They, too, must be able
to make and sustain contact with the client and with their own reactions.
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world, starting with awareness and attention. The therapist may simply help
her become aware of basic sights, sounds, somatic reactions, feelings, and
thoughts as well as what her attention drifts to. The immediate contact
between therapist and client is a component of the "now" where these
sensations are explored directly. The therapist might notice and ask about her
style of eye contact, or her fidgeting body, or stream of thoughts (e.g., "What is
it like to make eye contact now? What is the sensation in your body at this
moment?").
Sandra may also identify certain issues such as substance abuse,
relationship difficulties, and the threat of death from AIDS that seem to
dominate her life. The therapist might invite her to name and explore the
sensation that the thought of death, for example, brings; perhaps this involves
a sense of a void, or feeling cold and dark, or a feeling of engulfment. She then
may be asked to become these sensationsfor example, the therapist may
ask her to be "the void" and encourage her to speak as if she were that void.
This may then open possibilities for a dialog with the void through acting out
the opposite polarity: separateness and choice. This might involve using an
empty chair technique in which the client would literally move into the chair
of the "void," speak as if she were that, and then move into an opposite chair
and respond in a dialog. A therapist could also explore her introjection
through questions such as, "How is this void different or the same as from the
feeling of alcohol or in relationships with your children or husband?" She
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might also use this same technique to dialog with family members, or certain
aspects of herself.
Sandra seems to have a great deal of "unfinished business" that involves
unexpressed feelings (e.g., anger, longing, hurt). Experimentation with these
sensations may begin to free her to express and meet these feelings more
directly. All of this work encourages Sandra's experimentation with new ways
of relating both during and outside of the session in order to move into the
"here and now" and work toward the resolution of "unfinished business."
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empathy and support to elicit insight and choices. He strongly believes that
because people exist in the presence of others, the relational context of group
therapy is an effective approach (Yalom, 1980).
Preliminary observations and research indicate individuals with low
levels of perceived meaning in life may be prone to substance abuse as a
coping mechanism. Frankl first observed this possibility among inpatient
drug abusers in Germany during the 1930s (Frankl, 1959). Nicholson and
colleagues found inpatient drug abusers had significantly lower levels of
meaning in life when compared to a group of matched, nonabusing control
subjects (Nicholson et al., 1994). Shedler and Block performed a longitudinal
study and found that lower levels of perceived life meaning among young
children preceded substance abuse patterns in adolescence (Shedler and
Block, 1990).
In the context of treating substance abuse disorders, the existential
therapist often serves as a coach helping the client confront the anxiety that
tempts him to abuse substances. The client is then focused on taking
responsibility and making his own choices to remain substance free. If he
chooses to avoid the anxiety through substances, he cannot move forward to
find truth and authenticity. The challenge for the existential therapist is to
help the client make personal decisions about how to live, drawing upon
creativity and love, instead of letting outside events determine behavior.
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this by helping her understand that her life (like everyone else's) is finite.
Therefore, she is challenged to forge meaning from her life and make difficult
decisions about her relationships and ways of dealing (or not dealing) with
choices about substance abuse. The focus in her therapy would be on
choosing the life she wants to live. The therapist would assist her in dealing
constructively with anxiety so that she can find meaning in the rest of her life.
This could be accomplished by engaging her in the struggle to assume
authorship of her choices. She may be encouraged to "play out" scenarios of
choices she faces and acknowledge the accompanying fears and anxieties. She
might be asked, "What keeps you from sharing your fears with your husband,
and accepting the possibility of his support?" or "Imagine yourself expressing
your love for your children and regret for the mistakes you have made." Thus,
the therapist would help her understand that making difficult choices in the
face of death is actually a way to find integrity, wholeness, and meaning.
The teachings of the existential therapist, Yalom, can be a useful
resource in dealing with issues related to death, since he has worked with
terminally ill cancer patients for many years, helping them to use their crisis
and their danger as an opportunity for change (Yalom, 1998). Yalom explains
that although death is a primary source of anxiety for a client, incorporating
death into life can enrich life and allow one to live more purposefully.
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7
Brief Psychodynamic Therapy
Psychodynamic therapy focuses on unconscious processes as they are
manifested in the client's present behavior. The goals of psychodynamic
therapy are client self-awareness and understanding of the influence of the
past on present behavior. In its brief form, a psychodynamic approach
enables the client to examine unresolved conflicts and symptoms that arise
from past dysfunctional relationships and manifest themselves in the need
and desire to abuse substances.
Several different approaches to brief psychodynamic psychotherapy
have evolved from psychoanalytic theory and have been clinically applied to a
wide range of psychological disorders. A growing body of research supports
the efficacy of these approaches (Crits-Christoph, 1992; Messer and Warren,
1995).
Short-term psychodynamic therapies can contribute to the
armamentarium of treatments for substance abuse disorders. Brief
psychodynamic therapies probably have the best chance to be effective when
they are integrated into a relatively comprehensive substance abuse
treatment program that includes drug-focused interventions such as regular
urinalysis, drug counseling, and, for opioid-dependents, methadone
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Background
The theory supporting psychodynamic therapy originated in and is
informed by psychoanalytic theory. There are four major schools of
psychoanalytic theory, each of which has influenced psychodynamic therapy.
The four schools are: Freudian, Ego Psychology, Object Relations, and Self
Psychology.
Freudian psychology is based on the theories first formulated by
Sigmund Freud in the early part of this century and is sometimes referred to
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as the drive or structural model. The essence of Freud's theory is that sexual
and aggressive energies originating in the id (or unconscious) are modulated
by the ego, which is a set of functions that moderates between the id and
external reality. Defense mechanisms are constructions of the ego that
operate to minimize pain and to maintain psychic equilibrium. The superego,
formed during latency (between age 5 and puberty), operates to control id
drives through guilt (Messer and Warren, 1995).
Ego Psychology derives from Freudian psychology. Its proponents focus
their work on enhancing and maintaining ego function in accordance with the
demands of reality. Ego Psychology stresses the individual's capacity for
defense, adaptation, and reality testing (Pine, 1990).
Object Relations psychology was first articulated by several British
analysts, among them Melanie Klein, W.R.D. Fairbairn, D.W. Winnicott, and
Harry Guntrip. According to this theory, human beings are always shaped in
relation to the significant others surrounding them. Our struggles and goals in
life focus on maintaining relations with others, while at the same time
differentiating ourselves from others. The internal representations of self and
others acquired in childhood are later played out in adult relations.
Individuals repeat old object relationships in an effort to master them and
become freed from them (Messer and Warren, 1995).
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therapy need not include all analytic techniques and is not conducted by
psychoanalytically trained analysts. Psychodynamic therapy is also conducted
over a shorter period of time and with less frequency than psychoanalysis.
Several of the brief forms of psychodynamic therapy are considered less
appropriate for use with persons with substance abuse disorders, partly
because their altered perceptions make it difficult to achieve insight and
problem resolution. However, many psychodynamic therapists work with
substance-abusing clients, in conjunction with traditional drug and alcohol
treatment programs or as the sole therapist for clients with coexisting
disorders, using forms of brief psychodynamic therapy described in more
detail below.
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terms of their substance abuse before beginning this type of therapy (Mark
and Faude, 1995).
Mark and Faude theorized that substances of abuse substitute a
"chemical reaction" in place of experiences and that these chemically induced
experiences can block the impact of other external events. The person with a
substance abuse disorder will therefore have a "tremendously impoverished
and impaired capacity to experience," and traditional psychotherapy might
have to be augmented with techniques that focus on increasing a client's
ability to experience (Mark and Faude, 1995, p. 297).
Effective SE therapy depends on appropriate use of what is termed the
core conflictual relationship theme (CCRT), a concept first introduced by
Lester Luborsky. According to Luborsky, a CCRT is at the center of a person's
problems. The CCRT develops from early childhood experiences, but the
client is unaware of it and how it developed. It is assumed that the client will
have better control over behavior if he knows more about what he is doing on
an unconscious level. This knowledge is acquired by better understanding of
childhood experiences (Bohart and Todd, 1988). The CCRT develops out of a
core response from others (RO), which represents a person's predominant
expectations or experiences of others' internal and external reactions to
herself, and a core response of the self(RS), which refers to a more or less
coherent combination of somatic experiences, affects, actions, cognitive style,
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particular at how the RO and RS have contributed to the problem. The CCRT
framework also can be used to identify potential obstacles in the recovery
process as the therapist and client explore the client's anticipated responses
from others and from herself and discuss how these perceptions will change
when she stops abusing substances.
The CCRT concept also can help clients deal with relapse, which is
regarded by virtually all experts in the field as an integral and natural part of
recovery. Relapse offers the client and the SE therapist the opportunity to
examine how the RO and RS can serve as triggers and to devise strategies to
avoid these triggers in the future. Finally, SE therapy is conducive to client
participation in a self-help group such as Alcoholics Anonymous, or it can be
used as a mechanism to examine a client's unwillingness to participate in
these groups.
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but it is a big heart nonetheless, capable of caring for others with loyalty and
compassion. In addition, she has a tenacity of spirit; despite a horrific
personal history she completed her training as a medical technician and has
worked in that capacity for much of the last 4 years. Her therapist,
Christopher, is a well-trained psychodynamically oriented therapist. He is an
intelligent, serious, and measured person, whose well-meaning nature comes
through under most circumstances despite his natural reserve.
Stella has a history of polysubstance abuse, including the abuse of
prescription drugs, both anxiolytics and opioids. She worked as a medical
technician until she injured her back 3 months ago. At the beginning of
treatment, she told Christopher that she was going to request medication
from her physician for her back pain. After her eighth session, with her
reluctant agreement, Christopher informed the physician that she was in
treatment for cocaine dependence. Christopher asked the physician to find a
medication other than diazepam (Valium) for Stella's back pain.
Stella began the 19th session complaining that ever since the physician
found out she was a drug user, he has treated her differently. "He thinks I'm a
scumbag drug addict," she said. Christopher acted uncharacteristically: he
offered some advice. He suggested that Stella consider telling her physician
how she feels about his treatment. The intervention strikingly altered the
mood and productivity of the session. After a brief expression of sympathy for
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Her parents divorced when she was 10, and she lived with her mother, who
was often drunk and physically abusive. Stella said she was closer to her
father, whom she described as gentle. He appeared to others as weak and
ineffectual.
At age 15, Stella ran off with a boyfriend who was also her pimp. After 2
weeks she returned home, was unable to leave her mother, and was
diagnosed as having agoraphobia, for which she took chlordiazepoxide
(Librium). Two years later she ran away with another man, a particularly
sadistic pimp. For 5 years she was too terrified to leave him. It was during this
period that she started using cocaine.
The cocaine both "disclaims action" and affirms her "badness." Her
cocaine use enabled her to avoid examining why she stayed with her
boyfriend and simultaneously affirmed her badness. So, she deserves her fate.
She would use the cocaine to clear her painful feelings and feel "strong and
independent," then "feel like a big baby for having to use the drugs." She
thought of herself as a "big baby," for returning to her mother at age 15 and
for being unable to leave her current boyfriend. Her reactions to cocaine are
typical; a brief surge or a "high," followed by a crash. However, these typical
reactions also fit her core theme: she wants to be loved and cared for but
believes she will be thwarted and exploited by others because of this wish.
Her response then is to use drugs, which makes her feel strong and
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independent for a brief time and also makes her see herself as deserving of
being thwarted and exploited, which has happened repeatedly in
interpersonal contexts in her life.
Stella's drug use became a part of the therapy in two ways. In the first
session, Stella told Christopher that she had taken chlordiazepoxide for
several days before their appointment, to relieve her anxiety. She pointed out
that it had been prescribed by a doctor. Presumably, Christopher would have
known the results of her drug screen, which was part of the program. She
thus confessed before being confronted by drug screen results. Her claim that
the prescription was legitimate facilitated her denial that she has anything to
be concerned about.
Second, Stella announced her intention to ask her physician for
diazepam, a commonly abused medication. By contacting her physician,
Christopher replayed a common scenario in her life: she signals that someone
should take control or care for her, then resents it when they do, feeling that
she is being treated like a "scumbag drug addict." She can create the largely
illusory sense of being cared for when someone treats her as a helpless
incompetent. Was this how Christopher was treating her when he called her
physician?
When Christopher suggested that she tell the physician and the group
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therapist how she felt about the way they had treated her, his words may
have given advice, but his communication actually conveyed agreement with
Stella's position that she had been unfairly treated.
Stella experienced Christopher's agreement and support through his
intervention. However, what could have made this a more powerful
therapeutic interaction would have been either for Christopher to directly
acknowledge his misgivings about having taken charge and contacted the
physician or to explore how Stella came to hear his initial obliqueness as
giving her what she wantedhis care and support.
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stages of recovery. This study had at least two flaws, however. One was that
the therapists were not well-trained in SE therapy; therefore, it is
questionable whether or not the treatment they provided was actually SE
therapy. The other was that the therapy was provided in a municipal office
building where courts and social services were administered, thus this setting
lacked many features of traditional substance abuse treatment settings.
More recently, a large multisite study of 487 persons receiving
treatment compared SE therapy with cognitive therapy and drug counseling
for cocaine dependence (Crits-Christoph et al., 1997). Each of the three
conditions included, in addition to the individual treatment, a substance
abuse counseling group. A fourth condition received group counseling
without additional individual therapy. This study was a theoretical
descendant of the methadone studies mentioned earlier. It was hypothesized
that SE and cognitive therapy might be more effective than individual drug
counseling for clients with higher levels of psychiatric severity. The results
showed that each type of treatment was associated with significantly reduced
cocaine use. However, for this population of outpatient cocaine-dependent
clients, drug counseling was more successful at reducing substance use than
SE or cognitive therapy (Crits-Christoph et al., 1999). One implication of this
finding is that drug-focused interventions are perhaps the optimal approach
for providing treatment for substance abuse disorders (Strean, 1994).
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have worked with those who have substance abuse disorders are familiar
with "denial," even if they are not aware that this process is one of the
psychodynamic defense mechanisms. Counselors whose clients have an
immediate and strong negative reaction to them often benefit from an
understanding of the concept of "transference." It also is helpful for an alcohol
and drug counselor who is left feeling hopeless and confused after a session
to understand how "countertransference" could be at work. Therefore,
counselors who treat clients with substance abuse disorders can benefit from
understanding the basic concepts of general psychodynamic theory discussed
in this section, even if they do not use a strictly psychodynamic intervention.
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1985).
The psychodynamic model offers a systematic explanation of how the
therapeutic relationship works and guidelines for how to use it for positive
change and growth. In all psychodynamic therapies, the first goal is to
establish a "therapeutic alliance" between therapist and client. In most cases,
the development of a therapeutic alliance is partially a process of the passage
of time. The more severe the client's disorder, the more time it will take. The
capabilities of the therapist to be honest and empathic and of the client to be
trusting are also factors. A therapeutic alliance requires intimate selfdisclosure on the part of the client and an empathic and appropriate response
on the part of the therapist. However, in brief psychodynamic therapy this
alliance must be established as soon as possible, and therapists conducting
this sort of therapy must be able to establish a trusting relationship with their
clients in a short time.
One study of the therapeutic alliance and its relationship to alcoholism
treatment found that for alcoholic outpatients, ratings of the therapeutic
alliance by the patient or therapist were significant predictors of treatment
participation and of drinking behavior during treatment and at 12-month
followup, though the amount of variance explained was small (Connors et al.,
1997). Among cocaine-dependent patients, another study found that patients'
ratings of the therapeutic alliance predicted the level of current drug use at 1
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month but not at 6 months (Barber et al., 1999). The alliance at 1 month,
however, predicted improvement in depressive symptoms at 6 months. These
findings suggest that the therapeutic alliance exerts a moderate but
significant influence on outcome in the treatment of substance abuse
disorders. The specific outcomes measured vary from study to study but
include length of participation in treatment, reduction in drug use, and
reduction in depressive symptoms.
Developmental Level
Psychodynamic theory emphasizes that the client's level of functioning
should determine the nature of any intervention. In Freudian psychoanalytic
theory, substance abuse is considered a symptom associated with the oral or
most primitive stage of development and represents an attempt to establish a
need-gratifying symbiotic state (Leeds and Morgenstern, 1996). Analytic
theorists within the Object Relations school hold that substances stand in for
the functions usually attributed to the primary maternal (or care-giving)
object. As a result, the substance abuser relates to the substance based on the
disturbed pattern of relating that he experienced with the maternal object
(Krystal, 1977). This would be considered a variant of borderline
psychopathology, which is viewed as a fairly severe disturbance of ego
functioning and object relations. It is for this reason that substance-abusing
clients were and perhaps still are often considered unsuitable for
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Insight
Another critical underlying concept of psychodynamic theoryand one
that can be of great benefit to all therapistsis the concept of insight.
Psychodynamic approaches regard insight as a particular kind of selfrealization or self-knowledge, especially regarding the connections of
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experiences and conflicts in the past with present perceptions and behavior
and the recognition of feelings or motivations that have been repressed.
Insight can come through a sudden flash of understanding or from gradual
acquisition of self-knowledge. So, for example, a client who feels depressed
and angry and subsequently drinks comes to realize that his feelings toward
his father are stimulated by an emotionally abusive supervisor at work. This
type of realization gives the client new options. These options include
learning to separate his reactions to the supervisor from his feelings about his
father, working through his feelings about his father (of which he may not
have been previously aware), actively choosing alternative behaviors to
drinking when he feels bad (e.g., attending a 12-Step meeting), and accepting
greater responsibility for his feelings and behaviors.
A broader definition of insight, also promoted by brief psychodynamic
therapies, is simply any realization about oneself, one's inner workings, or
one's behavior. For example, a client who says, "the only emotion I really feel
is anger," has opened the door to understanding the effect others have on her,
and vice versa. She can then begin to develop alternative behaviors to those
that previously followed automatically from her anger (such as drinking), as
well as to understand why her emotional repertoire is so limited.
Insight involves both thoughts and feelings. A purely intellectual
exercise will not lead to behavior change. True insight involves a powerful
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Figure 7-1
Defense Mechanisms
Denial. Pretending that a threatening situation does not exist because the situation is too
distressing to cope with. A child comes home, and no one is there. He says to
himself, "They are here. I'll find them soon."
Displacement. Feelings and thoughts directed toward one person or object are directed
toward another person. For example, an employee has feelings of anger toward his
boss but is unaware of these feelings because of his internal conflict over
acknowledging them. Instead he becomes disproportionately angry at his wife over
a minor problem at home.
Grandiosity. Although not one of the originally identified analytic defenses, grandiosity is
frequently employed by substance abusers (Mark and Luborsky, 1992). Grandiosity
defends against unconscious low self-esteem by invoking self-deceptive, overly
positive opinions about oneself. An example of grandiosity in a substance-abusing
client is the client who insists that he can maintain control of drug use despite the
fact that he was using an increasingly large amount of drugs with increasing
frequency. This example can be seen as denial as well because denial involves
denying or minimizing the consequences of the addiction. However, the grandiosity
is evident in the user's unrealistic belief that he is in control of his drug use when it
would seem that his use is compulsive and clearly out of control at this point.
Identification with the aggressor. The activity of doing unto someone else what aroused
anxiety when it was done to oneself. A child has a tonsillectomy. She then puts on a
toy stethoscope and goes around pretending to take out the tonsils of her playmates.
Introjection. The individual "takes inside" himself what is threatening. For example, a
child feels strong anxiety about losing a parent's love when the latter admonishes
her for not cleaning her room. To cope with the anxiety she tells herself, "You are a
bad girl."
Isolation. Painful ideas are separated from feelings associated with them. To face the full
impact of sexual or aggressive thoughts and feelings, the ideas and affects are kept
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apart. For example, the thought of shouting obscenities in a church is kept separate
from all the rage about being in church. Thus, in isolation the individual may have
fleeting thoughts of an aggressive or sexual nature without any emotional
accompaniment.
Projection. This is the opposite of introjection; an intolerable idea or feeling is ascribed
to someone else. For example, it could be hypothesized that because the late Senator
Joseph McCarthy could not tolerate his own homosexual wishes, he spent much time
compiling lists of men in the State Department who, according to McCarthy, were
hiding their homosexuality.
Reaction formation. A painful idea or feeling is replaced by its opposite. A young girl, for
example, who cannot tolerate her hateful feelings toward her new baby brother
keeps saying, "I love my new brother!"
Regression. A retreat to an earlier form of behavior and psychic organization because of
anxiety in the present. For example, under the impact of anxiety stirred up by
wishes to masturbate, a teenager returns to an earlier form of behavior and resumes
sucking his thumb.
Repression. An attempt to exclude from awareness feelings and thoughts that evoke
anxiety. In repression, the feelings and thoughts may have been experienced
consciously at one time, or the repressive work may have stopped ideas and feelings
from ever reaching consciousness. For example, an individual may have consciously
experienced hateful feelings toward a parent or sibling but, because of the anxiety
evoked, blocked the feelings from awareness. Or to protect herself from feeling the
unpleasantness and dread of hate and anger, a woman never allows any hostile
thoughts or feelings to reach consciousness.
Undoing. Trying to remove an offensive act, either by pretending it was not done or by
atoning for it. For example, a boss hates an employee and wishes to fire him. Instead
he promotes the employee, thereby diminishing in his mind what he thinks he has
done.
Adapted from: Strean, 1994, pp. 13-15.
Transference
Effective use of the therapeutic relationship depends on an
understanding of transference. Transference is the process of transferring
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Etiology
Four contemporary analytic theorists have offered valuable
psychodynamic perspectives on the etiology of substance abuse disorders.
Wurmser, a traditional drive theorist, suggests that those with
substance abuse disorders suffer from overly harsh and destructive
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superegos that threaten to overwhelm the person with rage and fear. Abusing
substances is an attempt to flee from such dangerous affects. These affects are
the result of conflict between the ego and superego, brought about by the
harshness of the superego. Given this understanding, Wurmser's main focus
is the analysis of the superego. He believes that a moralistic stance toward the
substance-abusing behavior is counterproductive and that substance abusers'
problems consist of too much, rather than too little, superego. Wurmser
recommends that the therapist provide a strong emotional presence and a
warm, accepting, flexible attitude.
Khantzian theorizes that deficits, rather than conflicts, underlie the
problems of those with substance abuse disorders. That is, weakness or
inadequacies in the ego or self are at the root of the problem. Khantzian and
colleagues developed Modified Dynamic Group Therapy (MDGT) to address
these issues in a group therapy format, and this approach has some empirical
support. Khantzian put forth the self-medication hypothesis, which
essentially states that substance abusers will use substances in an attempt to
medicate specific distressing psychiatric symptoms (Khantzian, 1985). It
follows, then, that substance-dependent persons will express a strong
preference for a particular drug of choice to medicate their particular set of
symptoms. For example, those dependent on opioids are thought to be
medicating intense anger and aggression that their egos are unable to
contain. Cocaine-dependent people are believed to be seeking relief from
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are unresolved Oedipal conflicts, but loss, separation issues, and grief may
also be acceptable. Change comes about through the client's learning to
resolve an emotional core problem, essentially problem-solving. Resolving
the problem promotes a feeling of well-being and a corresponding positive
change in attitude.
Figure 7-2
Brief Psychodynamic Therapy
Therapy/
(Theorist)
Time-Limited
Psychotherapy
Length of
Treatment
12 sessions
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Focus
Major Techniques
Formulation,
presentation,
380
(Mann)
about loss
(lifelong source
of pain,
attempts to
master it, and
conclusions
drawn from it
regarding the
client's selfimage)
Short-Term AnxietyProvoking
Psychotherapy
(Nielsen and
Barth)
Usually 12 to 15
sessions
5 to 30 sessions;
up to 40
sessions for
severe
personality
disorders
SE Therapy
(Luborsky and
Mark)
16 for major
depression,
36 for
cocaine
dependence
and
interpretations
of the central
issue
Interpretation
around earlier
losses
Termination
Unresolved conflict
defined during
the evaluation
Early transference
interpretation
Experiencing and
linking
interpersonal
conflicts with
impulses,
feelings,
defenses, and
anxiety
Relentless
confrontation of
defenses
Supportive: creating
therapeutic
alliance through
sympathetic
listening
Confrontation /
clarification /
interpretations
Early transference
interpretation
Analysis of
character
defenses
Expressive:
formulating and
interpreting the
CCRT; relating
symptoms to the
CCRT and
explaining them
as coping
attempts
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Vanderbilt TimeLimited
Dynamic
Psychotherapy
(Binder and
Strupp)
25 to 30 sessions
Brief Adaptive
Psychotherapy
(Pollack,
Flegenheimer,
and Winston)
Up to 40 sessions
Change in
interpersonal
functioning,
especially
change in
cyclical
maladaptive
patterns
Transference
analysis within
an interpersonal
framework
Maladaptive and
inflexible
personality
traits and
emotions and
cognitive
functioning,
especially in
the
interpersonal
domain
Maintenance of
focus
Recognition,
interpretation of
the cyclical
maladaptive
pattern and
fantasies
associated with
it
Interpretation of the
transference
Recognition,
challenge,
interpretations,
and resolution
of early
resistance
High level of
therapist
activity
Dynamic Supportive
Psychotherapy
(Pinsker,
Rosenthal, and
McCullough)
Up to 40 sessions
Increase self-esteem,
adaptive skills,
and ego
functions
Self-esteem
boosters:
reassurance,
praise,
encouragement
Reduction of anxiety
Respect adaptive
defenses,
challenge
maladaptive
ones
Clarifications,
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reflections,
interpretations
Rationalizations,
reframing,
advice
Modeling,
anticipation, and
rehearsal
Self Psychology
(Baker)
Interpersonal
Psychotherapy
(Klerman)
12 to 30 sessions,
not rigidly
adhered to
Change intrapsychic
patterns.
Incorporate
more diverse
representations
of others and
changes in
information
processing
Analysis of the
mirroring,
idealizing, and
merger
transferences
Eliminating or
reducing the
primary
symptom;
improvement
in handling
current
interpersonal
problem areas,
particularly
those
associated with
substance
abuse
Exploration,
clarification,
encouragement
of affect,
analysis of
communication,
use of the
therapeutic
relationship and
behavior-change
techniques
Supportive,
empathic
Sources: Crits-Christoph and Barber, 1991; Klerman and Weissman, 1993; Rounsaville and
Carroll, 1993.
SE Psychoanalytic Psychotherapy
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A Self-Psychological Approach
The essential aspects of the theory of Self Psychology (Baker, 1991)
include the following:
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Empathy
The concept of the selfobject
The importance of the self in motivating behavior
The role of symptoms as the client's way of restoring selfcohesion
In this brief self-psychological therapy approach, one or two goals are
established collaboratively in the initial sessions. The duration of treatment
typically is 20 to 30 sessions, with fewer or more as needed. A selfobject is
something or someone else that is experienced and used as if it were part of
one's own self (Baker, 1991). For example, a child is dependent on the
parent's love and praise to develop a sense of self-worth and self-esteem. In
that way, the child internalizes a part of the parent as the selfobject. The
theory of change is that understanding, followed by interpretation, leads to
change. Success in therapy requires that dysfunctional intrapsychic
structures be changed and/or that compensating new structures be added.
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Other Research
In addition to Supportive-Expressive psychotherapy, both IPT and
MGDT have been studied as therapies for use in the treatment of substance
abuse disorders.
IPT has been evaluated as an adjunctive treatment for a full-service
methadone clinic (Rounsaville et al., 1983). This was a collaborative research
project that paralleled a study by Woody and colleagues (Woody et al., 1983).
Seventy-two methadone-maintained, opiate-dependent subjects who were
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8
Brief Family Therapy
Substance abuse disorders do not develop in isolation. For many
individuals with substance abuse disorders, interactions with the family of
origin, as well as the current family, set the patterns and dynamics for their
problems with substances. Furthermore, family member interactions with the
substance abuser can either perpetuate and aggravate the problem or
substantially assist in resolving it. Family therapy is suggested when the
client exhibits signs that substance abuse is strongly influenced by family
members' behaviors or communications with them. Family therapy might be
contraindicated if other family members are active substance abusers,
violent, deny that the client's substance abuse is problematic, or remain
excessively angry.
Family therapy is often used to examine factors that maintain a client's
substance abuse behavior. To understand these factors, the therapist
considers the family's various structural elements and how they contribute to
the substance abuse. These elements might include the power hierarchy,
roles, rules, alignments, and communication patterns within the family.
Through family therapy, the clinician can help the family identify
dysfunctional areas, adjust its hierarchy, change various roles that members
play, change dysfunctional rules, alter dysfunctional alignments between
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Contrary to what had long been the popular opinion, most individuals
with substance abuse disorders maintain close ties with their families.
Research has consistently shown that people with substance abuse disorders
are in closer contact with their families of origin than the members of the
general population of comparable age (Bekir et al., 1993; Douglas, 1987).
A number of reviews have found strong support for the use of family
therapy methods for substance abuse treatment. Recent research even
suggests that family and marital treatment produces better marital and
drinking outcomes than nonfamily methods (Lowinson et al., 1997). At least
one study that compared long-term and short-term family therapy (16 and 8
casework interventions over an 8- and a 4-month period, respectively) found
that shorter services were often more beneficial (Garvin et al., 1976).
However, comparable studies specifically on family therapy as applied to
substance abuse disorders are lacking.
The Harvard Medical School Department of Psychiatry successfully used
couples counseling in the context of treatment for alcohol-dependent clients.
Studies of participants in the Harvard Counseling for Alcoholics' Marriages
Project (Project CALM) showed that more than 50 percent of husbands with
alcohol abuse disorders who participated remained alcohol free in the first
year after treatment, compared with less than 30 percent of husbands treated
in individual therapy. Participants in the program also had fewer marital
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family therapy, the boundary between the therapist and the family is more
clear. In general, it is easier to continue to help an individual work within the
family system through subsequent individual therapy.
Some traditional approaches encourage clients to work on themselves
in isolation from others, but there are very few instances in which the
opportunity to work with a client's family for at least one or a few sessions
is not beneficial. Obviously, one such exception is when the client is
unwilling to pursue this approach. Another instance best dealt with
individually is when the client's situation involves issues of separation and
individuation although conjoint family work often helps complete this
process. Physical, emotional, or sexual abuse of the client by a family member
may also rule out family therapy. Short-term family therapy is an option that
could be used in the following circumstances:
When resolving a specific problem in the family and working
toward a solution
When the therapeutic goals do not require in-depth,
multigenerational family history, but rather a focus on
present interactions
When the family as a whole can benefit from teaching and
communication to better understand some aspect of the
substance abuse disorder
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Definitions of "Family"
The term "family therapy" evokes images of parents and children.
However, as mentioned above, family therapy can involve a network beyond
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the immediate family, may involve only one family member in treatment or a
few members of the family system, or may even include several families at
once.
Network therapy views substance abuse disorders from a cognitivebehavioral perspective (Galanter, 1993; Galanter et al., 1997; Keller et al.,
1997). In network therapy, significant nonfamily members, such as friends,
extended family members, cousins, and grandparents, as well as family
members, are regarded as useful resources available to assist the client.
In contrast, some types of family systems therapy regard substance
abuse as a symptom of an underlying pathology at work in the family. This
approach seeks to restructure the family and the maladaptive behaviors
which contribute to (or encourage) the client's substance abuse (Keller et al.,
1997).
Conjoint couples therapy addresses couples issues within the family
(Epstein and McCrady, 1998; Zweben et al., 1988). Typically, couples carry
out assignments in dealing with key therapeutic themes, such as listing the
factors that attracted each partner to the other, discussing how the
relationship could regain that attraction, and looking at expectations of each
partner, needs from the other partner, and resentments. Couples may need to
explore their ideas about gender roles within the relationship, or they may
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Theoretical Approaches
Many therapists are unfamiliar with effective ways to utilize supportive
family members and significant others when treating substance abuse
disorders (Bale, 1993; French, 1987; McCrady, 1991). This may stem in part
from reliance on popular concepts drawn from the traditional "family
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disease" model, in which family members of the substance user are seen as
suffering from the disease of "codependency" (Beattie, 1987; Coudert, 1972).
Cermak even defines codependency using criteria similar to those used in the
Diagnostic and Statistical Manual for Mental Disorders, 4th Edition [DSM-IV]
(Cermak, 1986). According to Schutt,
[T]he woman who lives with an alcoholic develops an
enabling illness. She constantly stands between the
alcoholic and his crises, thus enabling and condoning the
further usage of the drug (Schutt, 1985, p. 5).
From this perspective, family members of the person with a substance abuse
disorder "enable" the substance abuse to continue and so are thought to need
help "detaching" or disengaging from their over responsible involvement
with the substance user (Al-Anon, 1979; Bepko, 1985). As a result, treatment
often consists of a referral to Al-Anon and (less frequently) separate therapy
groups for family members that exclude the substance user (Frankel, 1992;
Friedman, 1990; McCrady, 1989; Regan et al., 1983).
Family systems models, on the other hand, instead of focusing on
individual personality disorders, generally regard substance abuse and
dependence as symptoms of dysfunctional interpersonal dynamics within the
family (Bowen, 1974; Gorad et al., 1971). From this perspective, the
substance abuse meets a need on some level for the family as a whole and
inadvertently reinforces the substance abuse (Davis et al., 1974; Stanton,
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1977). Chafetz and colleagues, for example, cite a family who laughed and
joked together while the father was intoxicated during an experimental
session in contrast to the same family's rather flat affect during a session
when the father was sober (Chafetz et al., 1974). The father's alcohol abuse
was seen as having become necessary for this family to express their positive
emotions. Based on similar anecdotal evidence, many family treatment
approaches have evolved that seek to identify the specific role or family-level
"adaptive function" served by substance abuse, with the goal of bolstering
interpersonal functioning in this area in order to reduce these secondary
gains from substance abuse for the individual and the family (Bepko, 1985;
Stanton and Todd, 1982; Steinglass et al., 1977). Several family treatment
models are described below.
Strategic family therapy (Haley, 1976) and the related Milan school of
family therapy (Selvini-Palazzoli et al., 1978) target the positive interpersonal
aspects of substance abuse specifically, acknowledging directly its benefits to
the family (e.g., "With your husband unemployed as a result of his drinking,
he can be home when the children get out of school"), as well as the negative
consequences the family might face if the substance abuse were to end (Fisch
et al., 1982; Haley, 1987). Together with such paradoxical interventions as
suggesting the family may not yet be ready to change, these interventions
often provoke "spontaneous" growth on the part of the family (Weeks and
L'Abate, 1979; Winn, 1995). See Chapter 5 in this TIP for more information on
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strategic and interactional therapies, which often involve the family directly.
Structural family therapy looks beyond the specific family dynamics
around substance abuse disorders to more general imbalances in family
relationships that might maintain substance abuse, such as extreme
disengagements and inappropriate coalitions between family members,
especially across generational lines (Minuchin, 1974). Salvadore Minuchin
has had an enormous impact on both the theory and practice of structural
family therapy, although many of his concepts have been modified as they
have been incorporated into the spectrum of modalities. Minuchin stressed
the importance of the hierarchy of power within the family and identifying
dysfunctional uses of power (e.g., "scapegoating"). It is important to
understand both healthy and dysfunctional roles within the family:
alignments, collusions, and communication patterns. These key points are
routinely explored in family therapy, although many therapists would not feel
comfortable "imposing" their own model of health on a familyan issue that
did not trouble Minuchin.
Structural therapists explore current family organization, especially
hierarchy and intimacy, while encouraging the family to loosen rules and
expectations that might be locking the substance abuser into a dysfunctional
role (Minuchin and Fishman, 1981; Stanton, 1977). In one of the earliest
applications of family therapy for substance abuse disorders, Stanton and
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In support of this particular finding, Stout and colleagues reported the same
pattern of improvement 2 years after a similar BMT trial with a different
sample of 229 clients with alcohol use disorders (O'Farrell and Cowles, 1989).
According to Noel and McCrady, this longterm effectiveness suggests
that marital therapy may prevent relapse during early recovery by stabilizing
the substance user's interpersonal context (Noel and McCrady, 1993). Similar
BMT approaches have recently been successfully employed with male
substance abusers and their partners (Fals-Stewart et al., 1996) and applied
in relapse prevention (McCrady, 1993) with booster sessions spread out over
the following year (O'Farrell et al., 1993). A BMT approach specifically for
female substance abusers is also being studied (Wetchler et al., 1993).
Network therapy approaches (Favazza and Thompson, 1984; Galanter,
1993) recognize the potential support from those outside the immediate
family, especially in terms of conducting effective substance abuse
interventions. Gathering together those who genuinely care about the welfare
of the substance abuser, especially friends and extended family members,
helps encourage the substance abuser to stop using and remain abstinent.
Galanter also points to the importance of the involvement of Alcoholics
Anonymous (AA) in network therapy (Galanter, 1993). Similarly, Selekman
has involved peer group members in family therapy with adolescent
substance users (Selekman, 1991). Piazza and DelValle have developed
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appropriately if the disulfiram is not taken (Sisson and Azrin, 1993). Besides
disulfiram and marital counseling, drinkers in the CRA programs receive job
and social skills counseling as needed. It is worth noting that some CRA
sessions have been held in the family's home (Hunt and Azrin, 1973),
recognizing the potential for home-based treatments (Henggeler et al., 1996).
In a study utilizing the CRA approach, 12 significant others of treatmentresistant clients with alcohol abuse disorders were randomly divided to form
a CRA group of seven and a control group of five who were referred to AlAnon. Of the CRA group, six of the seven resistant spouses entered treatment,
compared with none of the Al-Anon group partners. The partners of CRA
participants reduced their drinking days from 24 per month to 11 before
entering treatment, and this rate dropped to 2 drinking days per month once
the couple started joint treatment (Sisson and Azrin, 1986). (More
information on the CRA model can be found in Chapter 4 of this TIP.)
The CRA has been modified into the community reinforcement and
family training (CRAFT) procedure (Meyers et al., 1996) with clinical trials
under way (Meyers et al., 1998). This brief systemic intervention and therapy
model also works through the concerned other to analyze behavior patterns
surrounding substance abuse. Substance abuse triggers and consequences are
sought, as well as interpersonal cues and positive consequences that support
more adaptive, sober behaviors. This analysis can include the Spouse
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substance user's treatment status. Although much of the focus of the CRA and
CRAFT models centers on getting the substance abuser into treatment, both
programs emphasize the importance of ongoing family or couples sessions
employing communication skills training and marital reciprocity counseling
(Meyers et al., 1998; Sisson and Azrin, 1986).
Family therapy is often applied in the treatment of adolescents with
substance abuse disorders, and many specific family therapy models have
been developed for this population. These often weave together concepts and
techniques from different schools of family therapy. Multidimensional family
therapy (MDFT) (Liddle et al., 1992) is a brief family therapy model that has
demonstrated significant long-term clinical effectiveness in treating
adolescent substance abuse and conduct disorders during controlled trials
(Schmidt et al., 1996). MDFT integrates structural/strategic family therapy
(Stanton, 1981; Todd, 1986) with research findings on adolescent
development (Liddle et al., 1992). The MDFT model is designed to enhance a
family's ability to buffer adolescents against destructive peer and social
influences by nurturing healthy teen development through supportive rather
than strictly authoritarian parent-child relationships. Individual sessions with
the adolescent are interspersed with family sessions to allow the therapist an
opportunity to form a supportive relationship with the teen and act as an
intermediary between parent(s) and child. Besides relationship issues, the
MDFT model recognizes the developmental tasks faced by the adolescent,
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Others may require clients to bring in a significant other one to two nights
weekly to work together on recovery issues. Adolescent treatment programs
sometimes involve the family continuously throughout treatment.
Certain forms of family therapy have been developed to achieve a high
impact in a shorter period of time. One noted derivative of multifamily
therapy is the Multiple Impact Model developed by Wegscheider-Cruse
(1989), who brought together groups of four or five sober individuals who
were previously substance dependent and their families for a concentrated,
extended weekend of work. The purpose was to enable the families to
support the continued sobriety of their formerly substance-dependent
members. Family roles were recast so that each family member could take on
a different role, such as who would make family financial decisions. New
agreements between family members were written out. Permanent changes
often resulted with motivated families. Wegscheider-Cruse's work has been
replicated in several residential settings and training institutes (e.g., the OnSite and the Sierra Tucson Treatment Centers in Tucson, Arizona).
Opening Session
A typical opening session for a family in which a member has a
substance abuse disorder might involve the following:
The therapist seeks to clarify the nature of the problem and to
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Followup
Therapists should plan for followup and support as part of the
termination process. Residential programs, for example, can hold support
groups run by alumni or counselors that are available weekly for family
members who want to attend on a voluntary, as-needed basis. Some
practitioners ask the client and family members to call them after 6 months or
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Cultural Issues
It is important that a family therapist understand the family's ethnic and
cultural background. (See the example in the text box below.) Failure to do so
may be partially responsible for the large dropout rate by ethnic minorities
after the first therapy session (Soo-Hoo, 1999). To successfully promote
change within a family system, the therapist will need the family's permission
to share their closely held secrets. The therapist's approach, however, must
vary according to the cultural background of the family. Working with a
Filipino family recently settled in the United States, one therapist had to
request a letter from the family elder in the Philippines in order to allow
members to reveal family matters to an outsider. Once the family opened up,
however, the therapist was seen as an "elder" and was accorded the respect
he needed to promote positive change. In another example, a therapist
working with a client who belonged to the Southern Baptist fundamentalist
movement found that the client was immobilized by the shame that
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surrounded drinking in her family and the difficulty of talking about it. The
client approached the family's minister to help frame the situation so that the
family could face the problem together and find a solution. (For more
information on family therapy for those from unfamiliar cultures, see
McGoldrick et al., 1996; Sue and Sue, 1990.)
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9
Time-Limited Group Therapy
Group psychotherapy is one of the most common modalities for
treatment of substance abuse disorders. Group therapy is defined as a
meeting of two or more people for a common therapeutic purpose or to
achieve a common goal. It differs from family therapy in that the therapist
creates open- and closed-ended groups of people previously unknown to each
other. The lessons learned in therapy are practiced in the normal social
network. Although efficacy research on group therapy for substance abuse
disorder clients has been limited, there is substantial anecdotal and clinical
evidence that it can have a dramatic impact on participating clients. In TIP 8,
Intensive Outpatient Treatment for Alcohol and Other Drug Abuse (CSAT,
1994a), group therapy is cited as the treatment modality of choice for a
variety of reasons. In clinical practice, group psychotherapy offers individuals
suffering from substance abuse disorders the opportunity to see the
progression of abuse and dependency in themselves and in others; it also
gives them an opportunity to experience their success and the success of
other group members in an atmosphere of support and hopefulness. The
curative factors associated with group psychotherapy, defined by Yalom,
specifically address such issues as the instillation of hope, the universality
experienced by group members as they see themselves in others, the
opportunity to develop insight through relationships, and a variety of other
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Group Effects
One Consensus Panelist recalls a therapy session in which a member arrived,
furious and hostile, shouting, "How much longer do I have to do this stupid
program? None of it works anyway!" Another group member immediately asked,
"So, how does the anger keep things going for you?" In the ensuing conversation,
the group learned that the angry member's ex-wife had just sent him a bottle of
expensive whiskey with the following note: "Dying to get together again." This
revelation, and the supportive group listening that followed, occurred largely
without verbal involvement from the therapist.
Many beneficial effects happen more easily in groups than in one-onone therapy. Group members confront each other, do "reality checks,"
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practice reflective listening, mirror each other, and help each other reframe
key issues. Individuals in earlier stages of dependence can witness what later
stage experiences are like (and by inference where they could progress if they
do not reduce their use). Often, group members can be more effective than
the therapist in confronting a participant who is not facing an important issue
(e.g., the client who believes she can quit drinking and still smoke marijuana).
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the group. Through modeling and gentle persuasion, the group facilitator can
broaden the scope of a substance abuse treatment group to include
relationships, concerns about daily living, and newly discovered personal
integrity. Such are the struggles of all people in all circumstances. The
movement from "what is wrong with us" to "how do we build better lives?" is
an important transition in the time-limited group, whether psychoeducational
or process sensitive.
Group therapy can be conducted within the context of almost any
theoretical framework familiar to the therapist and appropriate to group
goals. Often the therapist will work with two or more models at the same
time. The theoretical bases supporting both process-sensitive groups and a
more directive style can be combined effectively to address substanceabusing clients.
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The cognitive-behavioral approach focuses the group's attention on selfdefeating beliefs, relying on group members to identify such beliefs in each
other. The therapist encourages group members to apply behavioral
techniques such as homework and visualization to help participants think,
feel, and behave differently. Chapter 4 discusses brief cognitive-behavioral
therapy in more depth.
Strategic/Interactional Therapies
The strategic therapist uses techniques similar to those used in family
therapy to challenge each group member to examine ineffective attempted
solutions. The therapist encourages group members to evaluate and process
these attempted solutions and recognize when they are not working, then
engages the group in generating alternative solutions. The therapist also
works, where appropriate, to change group members' perceptions of
problems and help them understand what is happening to them. Typically,
the therapist guides the process, while members offer suggestions and
encouragement to each other as they identify and implement effective
solutions. To address the problem of substance abuse, the group will often be
directed to examine problems that might result in substance abuse and
reframe their perceptions of these problems.
The principles of solution-focused therapy are the same for group
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Each group member plays a role in creating the group, and all of their
perceptions must be taken into account in making a change. Role-playing and
dream analysis in groups are practical and relevant exercises that can help
clients come to terms with themselves.
One of the most influential contemporary experts on group therapy,
Irvin D. Yalom, considers himself an existentialist because he is not concerned
with past behavior except as it influences the "here and now." A summary of
his existential approach is presented in The Yalom Reader (Yalom, 1997) and
consists of three sections: (1) therapeutic factors in group therapy, (2) a
description of the "here and now" core concept, and (3) therapy with
specialized groups, including a chapter on group therapy and alcoholism. This
last chapter details specific techniques to diminish anxiety but still permit the
group to maintain an interactional focus for example, writing a candid
summary of the session and mailing it to members before the next meeting.
Yalom has worked closely with the National Institute on Alcohol Abuse and
Alcoholism to apply basic principles of group therapy to alcohol abusers, and
his ideas are applicable to those with other substance abuse disorders as well.
See Chapter 6 for more discussion of humanistic and existential therapies.
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the context and means of change through which its members stimulate each
other to support, strengthen, or change attitudes, feelings, relationships,
thinking, and behaviorwith the assistance of the therapist.
The context sought is one in which the group becomes an
influential reference group for the individual. Participation
of members according to their abilities leads to some
degree of involvement of each in pursuing individual and
group goals. The process of goal-setting and clarification for
expectation provides an agreed upon framework for
meeting of mutual needs. This, in turn, contributes to the
building of cohesive forces (Roberts and Northen, 1976, p.
141).
Chapter 7 discusses psychodynamic therapy in more depth.
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the group and conceptualizes the basic origins of substance abuse disorders
as expressions of vulnerabilities within the characterological makeup of the
client (Khantzian et al., 1990). As a supportive, expressive group experience,
MDGT provides substance-abusing clients the opportunity to evaluate and
change their vulnerabilities in four primary areas: (1) accessing, tolerating,
and regulating feelings; (2) problems with relationships; (3) self-care failures;
and (4) self-esteem deficits. Congruent with this understanding of the origins
of substance abuse, MDGP emphasizes safety, comfort, and control within the
group context. Group facilitation is defined primarily by the therapist's ability
to engage and retain substance abusers in treatment by providing structure,
continuity, and activity in an empathic atmosphere.
This supportive approach creates an atmosphere of safety, allowing the
client to move away from the safety of the known behavior associated with
substance abuse and into the less known world of recovery. As in other group
experiences, this group theory encourages issues of universality as a means of
overcoming isolation, while at the same time dealing with a common shame
so often encountered in the substance-abusing client. Unlike interpersonally
focused process groups, which look more at relational concerns, MDGT places
greater emphasis on the clients' growing understanding of their
characterological difficulties and/or deficits, not entirely dissimilar to issues
identified in self-help groups such as A A and NA.
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accepting responsibility for itself, and self-disclosure are all supported by the
facilitator. Procedural agreements, including beginning and ending the group
session on time and ensuring that each member has a place within the circle,
with any absences addressed, are part of the development of the safe
environment.
In this process, the therapist helps the clients recognize that they are
the primary change agents. The group becomes a safe place both to give and
to receive support. Although traditionally substance abuse groups tend to be
confrontative, MIGP is far more supportive. This stems from the belief that
denial and other defense mechanisms become more rigid when a person is
attacked. Consequently, group members are encouraged to support one
another and look for areas of commonality rather than use more shame-based
interactive styles that attempt to "break through denial."
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within the group, taking steps to break emotional contagion should it begin.
In a particularly intense group experience, the therapist may ask the group as
a whole to take a step back and look at what just took place. In this way, the
group not only learns from its shared life but also experiences its ability to
control intense emotional responses. This consistent effort to reduce high
levels of anxiety or emotional catharsis and to prevent them from dominating
the group is another hallmark of MIGP.
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Vulnerability of self
Substance-abusing clients often enter treatment with shattered selfesteem. Defending against this internal vulnerability can become damaging,
because clients project their fears onto others. They may try to hide internal
vulnerability by appearing hostile and overly self-confident. An atmosphere
of safety and empathy enables clients with profound vulnerabilities to enter
the process of self disclosure, through which they become accessible not only
to the group but also to themselves. The group facilitator actively encourages
such self-disclosure but at the same time emphasizes that individual
members need not disclose any issue they are not yet ready to discuss. Clear
boundaries and clear group agreements further support the possibility for
self-disclosure.
Regulation of affect
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Self-care
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therapist might highlight the fact that the mother and father communicate
through one of their children and never talk to each other directly.
In yet another form of psychodrama, one person in the group may be
asked to give voice to different aspects of her own self that either help
maintain dependency or speak for change (sometimes called the "disease"
and "recovery" selves). The client might speak from a different chair or
position for each of these voices. The intensity of psychodrama often helps
compensate for the shorter time span now commonly funded for treatment.
Although many participants express concern about acting, the barrier of
shyness often drops completely as they enter the process with the assistance
of a dynamic and committed facilitator.
Therapeutic Factors
In his classic work, Theory and Practice of Group Psychotherapy, Irvin
Yalom identified 11 primary "therapeutic factors" in group therapy (Yalom,
1995). Each of these factors has particular importance for clients with
substance abuse disorders and can be used to help explain why a group
works in a particular way for this client population. These curative factors are
present in all group interventions and are listed below.
Instillation of Hope
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Universality
Substance abuse disorders tend to impede relationships and force
clients into increased isolation. In a brief group experience, the clients
encounter other individuals who have faced similar problems. They become
aware that they are not alone in life and can feel tremendous satisfaction in
this connection. The sense that their pain is not exclusive or unique and that
others with similar problems are willing to support them can be profoundly
healing. It helps clients move beyond their isolation, and it gives further
energy to hope, which helps to fuel the change process.
Imparting Information
The inevitable exchange of information in a group setting helps
members get from one day to the next. Particularly in conjunction with formal
psychoeducational groups, MIGP affords group members the opportunity to
reflect on what they have learned and at the same time apply that learning
within the group setting. The information shared is personal and tends to be
experienced as motivational. The client struggling with issues of substance
abuse can hear from others how they have dealt with difficult concerns and
how they have experienced success. This mutually shared success gives
positive energy to the group and encourages change.
Altruism
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Imitative Behaviors
Imitative behaviors are an important source of learning in group
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Interpersonal Learning
Groups provide an opportunity for members to learn about
relationships and intimacy. The group itself is a laboratory where group
members can, perhaps for the first time, honestly communicate with
individuals who will support them and provide them with respectful
feedback. This interpersonal learning is facilitated by the MIGP model, in that
special attention is given to relational issues within the context of group.
Group Cohesiveness
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Catharsis
Sometimes group participants will gain a sudden insight through
interaction with others, which can cause a significant internal shift in the way
they respond to life. Such insights may be accompanied by bursts of emotion
that release pain or anger associated with old psychological wounds. This
process happens more easily in a group where cohesion has been developed
and where the therapist can facilitate a safe environment in which emotions
can be freely shared. It is important to recognize, however, that although
catharsis is a genuine expression, it is not seen as curative in and of itself.
High levels of emotional exchange not addressed in the group can become
potential relapse triggers, which endanger the success of individual members.
The therapist acknowledges the powerful emotions after the member has
shared them but asks the group as well as the member to give those emotions
meaning and context within the group. Thus, both the experience of the
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Existential Factors
Existential factors of loss and death are often issues of great discomfort
in the substance-abusing population. The brevity of a time-limited group
experience forces these issues to the surface and allows members to discuss
them openly in a safe environment. Time itself represents loss and also serves
as a motivator, as the members face the ending of each group session and of
the group treatment experience. As they become more aware of the
frustrations of reality and the limits they face, clients can receive support
from the group in accepting "life on life's terms" instead of their past patterns
of escape.
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releases for client permission, to use for instructional purposes. This enables
new clients to see what will happen in the group session and lowers anxiety.
This intentional effort to make the group safe and reduce its inherent anxiety
distinguishes MIGP from a more traditionally interactive process group.
Introductions to group can also be provided in a psychoeducational format.
Clients learn not only what is going to take place in the group but also why
and how the group process brings about healing. The importance of
relationships and open communications through self-disclosure and support
can be explained.
It is important to recognize that although a significant amount of client
preparation takes place before the client ever enters a group, client
preparation itself is also a process and not an event. Through continual
references to the group agreements and group contracts, the therapist
continues to prepare clients as they move into the experience.
Initial Session
Opening sessions for group therapy differ according to the type of
group, its specific goals, and the personal style of the therapist. In
homogeneous, problem-focused groups, for example, less time is needed to
define what group members have in common. Opening sessions typically
include the following:
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Some therapists ask the group to evaluate the opening session. This may
be done orally or in writing. The group's success can be measured through
the following questions:
Was substance abuse discussed?
Did group members listen to each other?
Did members cooperate and support each other?
Did they give feedback?
Later Sessions
Often, to enhance continuity, the therapist will begin the next session by
recalling the previous one and ensuring that "leftover" items are addressed.
The therapist may ask group members how lessons learned in the group have
affected their daily lives. Members may have tried to implement suggestions
and found they did or did not work, or they may not have tried to do so at all,
which is also an important topic of discussion.
On an inpatient unit with clients going through withdrawal or struggling
with coexisting psychiatric disorders, instilling hope is particularly important.
For the newest clients on the unit, connecting with others who have just been
through a similar difficult experience can be inspirational. Such a therapeutic
encounter can also reduce issues of shame, as clients connect with others who
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both share and understand their journey. In addition, the inpatient group can
serve as an example of what treatment will be like after discharge and allow
the client to "practice" being in a group. Clients can experience the supportive
nature of the group, which will reduce their anxiety about future group
involvement. Underscoring the impact of brief group interventions, the
inpatient process treatment group remains one of the cornerstones of
continued change.
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can build cohesion quickly and act as powerful motivators for clients to follow
through with the next level of care.
Group process therapy is most effective if participants have had time to
find their roles in a group, to "act" these roles, and to learn from them. The
group needs time to define its identity, develop cohesion, and become a safe
environment in which there is enough trust for participants to reveal
themselves. (The exception is an educational group, which relies less on
group process factors.) Consequently, prematurely terminated groups relying
on group process may be less effective than they could be in promoting longterm change. Furthermore, participants may have to clear their systems of the
most serious effects of substances before they can fully participate. Because of
such factors, arbitrary time limits for groups, as opposed to timelines set
according to the therapeutic goals of the particular group, can be ill advised.
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men, perhaps because groups are often dominated by men and reflect their
issues and style of interaction (Jarvis, 1992). At this time, however, little
research is available on the relative efficacy of women-only rather than
mixed-gender groups. Weitz argues that women may have to be empowered
in order to remain abstinent (Weitz, 1982). Group cognitive-behavioral
therapy has been found to be an effective treatment for women with
posttraumatic stress disorder and a substance abuse disorder (Najavits et al.,
1996) as well as for women with both a substance abuse disorder and a
history of physical or sexual abuse (Manisses Communication Group, 1997).
Covington has written extensively about the importance of womenspecific groups, particularly in early recovery. She accurately pointed out that
the powerful role definitions within our culture tend to be played out in
group and are often oppressive to women (Covington, 1997). In a mixed
group, the women quickly become the "emotional containers" for the group
and take care of the men. Although such activity is not defined as pathological,
it expresses cultural norms wherein women's needs become secondary to
those of men, with the women primarily defined as caretakers. They are
uncomfortable about bringing up issues of sexuality, particularly sexual
abuse, given that men have generally been the abusers (Covington, 1997).
The creation of gender-specific groups, particularly in small agencies or
private practice, may pose logistical difficulties. However, there is growing
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Cost-Effectiveness
The clinical utility of time-limited groups has clearly been
demonstrated, but the cost factor is not irrelevant to a consideration of the
value of these groups. Although individual work and family work will likely
always remain a part of even the briefest time-limited treatment experience,
acceptance and use of group interventions are slowly growing. From a costmanagement perspective, the benefits are obvious. Not only can the therapist
use the power of the group to support change within all group members, but
one well-trained group therapist can meet the clinical needs of 8 to 12 clients
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Appendix A
Bibliography
Abbott, P.J.; Weller, S B.; Delaney, H.D.; and Moore, B.A. Community reinforcement approach in
the treatment of opiate addicts. American journal of Drug and Alcohol Abuse
24(1):1730,1998.
Ablon, J. The significance of cultural patterning for the "alcoholic family." Family Process
19(2):127-144,1980.
Abrams, D.B., and Niaura, R.S. Social learning theory. In: Blane, H.T., and Leonard, K.E., eds.
Psychological Theories of Drinking and Alcoholism. New York: Guilford Press, 1987.
pp. 131-178.
Abramson, L.Y.; Seligman, M.E.; and Teasdale, J.D. Learned helplessness in humans: Critique and
reformulation. Journal of Abnormal Psychology 87(1):49-74,1978.
Ackerman, R. Growing in the Shadow: Children of Alcoholics. Pompano Beach, FL: Health
Communications, 1986.
Ackerman, R. Motto for ACOAs: Let go and grow. Recovery Section, Alcoholism and Addiction
7(5):R10, 1987.
Aktan, G.B.; Kumpfer, K.L.; and Turner, C.W. Effectiveness of a family skills training program for
substance abuse prevention with inner city African-American families. Substance
Use and Misuse 31(2):157-175, 1996.
Al-Anon Family Groups, Inc. Al-Anon Faces Alcoholism. New York: Al-Anon Family Group
Headquarters, 1984.
Allen, J.P., and Columbus, M. Assessing Alcohol Problems: A Guide for Clinicians and Researchers.
NIAAA Treatment Handbook Series, No. 4. Bethesda, MD: Department of Health
and Human Services, 1995.
Alonso, A., and Rutan, J.S. Women in group therapy. International Journal of Group Psychotherapy
http://www.freepsychotherapybooks.org
464
29(4):481-491,1979.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed.
Washington, DC: American Psychiatric Press, 1980.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
Washington, DC: American Psychiatric Press, 1994.
American Society of Addiction Medicine (ASAM). Principles of Addiction Medicine. Chevy Chase,
MD: ASAM, 1994.
American Society of Addiction Medicine (ASAM). Patient Placement Criteria for the Treatment of
Substance-Related Disorders, 2nd ed. Chevy Chase, MD: ASAM, 1996.
Amodeo, M. Treating the late life alcoholic: Guidelines for working through denial integrating
individual, family, and group approaches, journal of Geriatric Psychiatry 23(2):91
105, 1990.
Anderson, P., and Scott, E. The effect of general practitioners' advice to heavy drinking men.
British Journal of Addiction 87(6):891-900, 1992.
Anker, A.L., and Crowley, T.J. Use of contingency contracts in specialty clinics for cocaine abuse.
In: Harris, L.S., ed. Problems of Drug Dependence, 1981. Proceedings of the 43rd
Annual Scientific Meeting, the Committee on Problems of Drug Dependence, Inc. NIDA
Research Monograph Series, Number 41. DHHS Pub. No. (ADM) 83-1264. Rockville,
MD: National Institute on Drug Abuse, 1982. pp.452-459.
Annis, H.M., and Davis, C.S. Assessment of expectancies. In: Donovan, D.M., and Marlatt, G.A., eds.
Assessment of Addictive Behaviors. New York: Guilford Press, 1988a. pp.84-111.
Annis, H.M., and Davis, C.S. Self-efficacy and the prevention of alcoholic relapse: Initial findings
from a treatment trial. In: Baker, T.B., and Cannon, D.S., eds. Assessment and
Treatment of Addictive Disorders. New York: Praeger Publishers, 1988b. pp. 88-112.
Annis, H.M., and Davis, C.S. Relapse prevention. In: Hester, R.K., and Miller, W.R., eds. Handbook of
Alcoholism Treatment Approaches. Elmsford, NY: Pergamon Press, 1989a. pp. 170-
465
182.
Annis, H.M., and Davis, C.S. Relapse prevention training: A cognitive-behavioral approach based
on self-efficacy theory. Journal of Chemical Dependency Treatment 2(2):81103,1989b.
Annis, H.M., and Davis, C.S. Relapse prevention. Alcohol Health & Research World 15(3):204212,1991.
Azrin, N.H. Improvements in the community-reinforcement approach to alcoholism. Behaviour
Research and Therapy 14(5):339-348, 1976.
Babor, T.F. Nosological considerations in the diagnosis of substance abuse disorders. In: Glantz,
M., and Pickens, R., eds. Vulnerability to Drug Abuse. Washington, DC: American
Psychological Association, 1991. pp. 53-73.
Babor, T.F. Avoiding the horrible and beastly sin of drunkenness: Does dissuasion make a
difference? journal of Consulting and Clinical Psychology 62(6):1127-1140, 1994.
Babor, T.F., and Grant, M., eds. Project on Identification and Management of Alcohol-Related
Problems. Report on Phase II: A Randomized Clinical Trial of Brief Interventions in
Primary Health Care. Geneva, Switzerland: World Health Organization, 1991.
Babor, T.F.; Grant, M.; Acuda, W.; Burns, F.H.; Campillo, C.; Del Boca, F.K.; Hodgson, R.; Ivanets,
N.N.; Lukomskya, M.; Machona, M.; Rollnick, S.; Resnick, R.; Saunders, J.B.; Skutle, A.;
Connor, K.; Ernberg, G.; Kranzler, H.; Lauerman, R.; and McRee, B. A randomized
clinical trial of brief interventions in primary health care: Summary of a WHO
project. Addiction 89(6):657-660,1994.
Babor, T.F.; Ritson, E.B.; and Hodgson, R.J. Alcohol-related problems in the primary health care
setting: A review of early intervention strategies. British Journal of Addiction 81:2346,1986.
Baker, H.S. Shorter term psychotherapy: A self-psychological approach. In: Crits-Christoph, P.,
and Barber, J.P., eds. Handbook of Short-Term Dynamic Psychotherapy. New York:
Basic Books, 1991. pp. 287-322.
http://www.freepsychotherapybooks.org
466
Bale, R. Family treatment in short-term detoxification. In: O'Farrell, T. J., ed. Treating Alcohol
Problems: Marital and Family Interventions. New York: Guilford Press, pp. 117-144.
Bandura, A. Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review
84(2):191-215, 1977.
Bandura, A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs,
NJ: Prentice-Hall, 1986.
Bandura, A. Regulative function of perceived self-efficacy. In: Rumsey, M.G.; Walker, C.B.; and
Harris, J.H., eds. Personnel Selection and Classification. Hillsdale, NJ: Lawrence
Erlbaum Associates, 1994. pp. 261-271.
Barber, J.P., and Crits-Christoph, P. Comparison of the brief dynamic therapies. In: CritsChristoph, P., and Barber, J.P., eds. Handbook of Short-Term Dynamic Psychotherapy.
New York: Basic Books, 1991. pp. 323-357.
Barber, J.P.; Luborsky, L.; Crits-Christoph, P.; Thase, M.E.; Weiss, R.; Frank, A.; Onken, L.; and
Gallop, R. Therapeutic alliance as a predictor of outcome in treatment of cocaine
dependence. Psychotherapy Research 9:54-73, 1999.
Barry, K.L. Alcohol and drug abuse. In: Mengel, M.B., and Holleman, W.L., eds. Fundamentals of
Clinical Practice: A Textbook on the Patient, Doctor, and Society. New York: Plenum
Medical Book Co., 1997. pp. 335-357.
Barry, K.L., and Blow, F.C. Basic Health Promotion Workbook. Ann Arbor, MI: University of
Michigan Press, 1998.
Barth, R.P.; Ramler, M.; and Pietrzak, J. Toward more effective and efficient programs for drugand AIDS-affected families. In: Barth, R.P.; Pietrzak, J.; and Ramler, M., eds. Families
Living With Drugs and HIV: Intervention and Treatment Strategies. New York:
Guilford Press, 1993. pp. 337-353.
Bauer, G.P., and Kobos, J.C. Brief Therapy: Short-Term Psychodynamic Intervention. Northvale, NJ:
Jason Aronson, 1987.
467
http://www.freepsychotherapybooks.org
468
1965.
Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief interventions for alcohol problems: A review.
Addiction 88:315-336,1993.
Bigelow, G.E.; Stitzer, M.L.; and Liebson, I.A. The role of behavioral contingency management in
drug abuse treatment. In: Grabowski, J.; Stitzer, M.L.; and Henningfeld, J.E., eds.
Behavioral Intervention Techniques in Drug Abuse Treatment. NIDA Research
Monograph Series, Number 46. DHHS Pub. No. (ADM) 84-1282. Rockville, MD:
National Institute on Drug Abuse, 1984. pp. 36-52.
Binder, J.L., and Strupp, H.H. The Vanderbilt approach to time-limited dynamic psychotherapy. In:
Crits-Christoph, P., and Barber, J.P., eds. Handbook of Short-Term Dynamic
Psychotherapy. New York: Basic Books, 1991. pp. 137-165.
Bion, W.R. Experiences in Groups, and Other Papers. New York: Basic Books, 1961.
Birchler, G.R., and Webb, L.J. Discriminating interaction behaviors in happy and unhappy
marriages. Journal of Consulting and Clinical Psychology 45:494-495, 1977.
Birke, S.A.; Edelmann, R.J.; and Davis, P.E. An analysis of the abstinence violation effect in a
sample of illicit drug users. British Journal of Addiction 85(10):1299-1307,1990.
Blaine, J.D., and Julius, D.A., eds. Psychodynamics of Drug Dependence. NIDA Research Monograph
Series, Number 12. DHEW Pub. No. (ADM) 77-470. Rockville, MD: National Institute
on Drug Abuse, Division of Research, 1977.
Blatt, S.J.; Quinlan, D.M.; Pilkonis, P.A.; and Shea, M.T. Impact of perfectionism and need for
approval on the brief treatment of depression: The National Institute of Mental
Health Treatment of Depression Collaborative Research Program revisited. Journal
of Consulting and Clinical Psychology 63(1):125132,1995.
Blewett, D.B. The Frontiers of Being. New York: Award, 1969.
Bloom, B.L. Planned Short-Term Psychotherapy: A Clinical Handbook, 2nd ed. Boston: Allyn and
Bacon, 1997.
469
Bohart, A.C., and Todd, J. Foundations of Clinical and Counseling Psychology. New York: Harper &
Row, 1988.
Boorstein, S., ed. Transpersonal Psychotherapy. Palo Alto, CA: Science and Behavior Books, 1980.
Boszormenyi-Nagy, I., and Spark, G. Invisible Loyalties: Reciprocity in Intergenerational Family
Therapy. Hagerstown, MD: Harper & Row, 1973.
Bowen, M. Alcoholism as viewed through family systems theory and family psychology. Annals of
the New York Academy of Sciences 233:115-122,1974.
Bowen, M. Family Therapy in Clinical Practice. New York: Jason Aronson, 1978.
Bowlby, J. Attachment and Loss. New York: Basic Books, 1969.
Bradley, B.P.; Gossop, M.; Brewin, C.R.; Phillips, G.; and Green, L. Attributions and relapse in opiate
addicts. Journal of Consulting and Clinical Psychology 60(3):470-472,1992.
Brill, L. The Clinical Treatment of Substance Abusers. New York: Free Press, 1981.
Brooks, C.S.; Zuckerman, B.; Bamforth, A.; Cole, J.; and Kaplan-Sanoff, M. Clinical issues related to
substance-involved mothers and their infants. Infant Mental Health Journal
15(2):202-217,1994.
Brown, J.M., and Miller, W.R. Impact of motivational interviewing on participation and outcome in
residential alcoholism treatment. Psychology of Addictive Behaviors 7:211218,1993.
Brown, S.A. Drug effect expectancies and addictive behavior change. Experimental and Clinical
Psychopharmacology 1(1-4):55-67, 1993.
Brown, S.A.; Carrello, P.D.; Vik, P.W.; and Porter, R.J. Change in alcohol effect and self-efficacy
expectancies during addiction treatment. Substance Abuse 19(4):155167, 1998.
Brown, S.A.; Christiansen, B.A.; and Goldman, M.S. Alcohol Expectancy Questionnaire: An
instrument for the assessment of adolescent and adult alcohol expectancies.
http://www.freepsychotherapybooks.org
470
471
Campbell, T. Parental conflicts between divorced spouses: Strategies for intervention. Journal of
Systemic Therapies 12(4):27-38,1993.
Cappell, H. Alcohol and tension reduction: What's new? In: Gottheil, E.; Druly, K.A.; Pashko, S.; and
Weinstein, S.P., eds. Stress and Addiction. New York: Brunner/Mazel, 1987. pp. 237247.
Carroll, K.M. Integrating psychotherapy and pharmacotherapy in substance abuse treatment. In:
Rotgers, F.; Keller, D.S.; and Morgenstern, J., eds. Treating Substance Abuse: Theory
and Technique. New York: Guilford Press, 1996a.
Carroll, K.M. Relapse prevention as a psychosocial treatment: A review of controlled clinical
trials. In: Marlatt, G.A., and VandenBos, G.R., eds. Addictive Behaviors: Readings on
Etiology, Prevention, and Treatment. Washington, DC: American Psychological
Association, 1996b. pp. 697-717.
Carroll, K.M. Therapy Manuals for Drug Addiction. Manual 1: A Cognitive-Behavioral Approach:
Treating Cocaine Addiction. Rockville, MD: National Institute on Drug Abuse, 1998.
Carroll, K.M.; Rounsaville, B.J.; and Gawin, F.H. A comparative trial of psychotherapies for
ambulatory cocaine abusers: Relapse prevention and interpersonal psychotherapy.
American Journal of Drug and Alcohol Abuse 17:229-247,1991.
Carson, R.C., and Butcher, J.N. Abnormal Psychology and Modern Life, 9th ed. New York:
HarperCollins, 1992.
Center for Substance Abuse Treatment. Screening and Assessment of Alcohol- and Other DrugAbusing Adolescents. Treatment Improvement Protocol (TIP) Series, Number DHHS
Pub. No. (SMA) 93-2009. Washington, DC: U.S. Government Printing Office, 1993a.
Center for Substance Abuse Treatment. Guidelines for the Treatment of Alcohol and Other
Substance-Abusing Adolescents. Treatment Improvement Protocol (TIP) Series,
Number 4. DHHS Pub. No. (SMA) 2010. Washington, DC: U.S. Government Printing
Office, 1993b.
Center for Substance Abuse Treatment. Intensive Outpatient Treatment for Alcohol and Other Drug
Abuse. Treatment Improvement Protocol (TIP) Series, Number 8. DHHS Pub. No.
http://www.freepsychotherapybooks.org
472
473
No. (SMA) 99-3282. Washington, DC: U.S. Government Printing Office, 1999a.
Center for Substance Abuse Treatment. Treatment of Adolescents With Substance Use Disorders.
Treatment Improvement Protocol (TIP) Series, Number 32. DHHS Pub. No. (SMA)
99-3283. Washington, DC: U.S. Government Printing Office, 1999b.
Center for Substance Abuse Treatment. Enhancing Motivation for Change in Substance Abuse
Treatment. Treatment Improvement Protocol (TIP) Series, Number 35. DHHS Pub.
No. (SMA) 99-3354. Washington, DC: U.S. Government Printing Office, 1999c.
Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With HIV/AIDS.
Treatment Improvement Protocol (TIP) Series. Washington, DC: U.S. Government
Printing Office, in press.
Cermak, T.L. Diagnosing and Treating Co-Dependence: A Guide for Professionals Who Work With
Chemical Dependents, Their Spouses, and Children. Minneapolis, MN: Johnson
Institute, 1986.
Chafetz, M.E.; Blane, H.T.; Abram, H.S.; Golner, J.; Lacy, E.; McCourt, W.F.; Clark, E.; and Meyers, W.
Establishing treatment relationships with alcoholics, journal of Nervous and Mental
Disease 134(5):395-409, 1962.
Chafetz, M.E.; Hertzman, M.; and Berenson, D. Alcoholism: A positive view. In: Arieti, S., and
Brody, E.B., eds. Adult Clinical Psychiatry, 2nd ed. American Handbook of
Psychiatry, Vol. 3. New York: Basic Books, pp. 367-392.
Chaney, E.F. Social skills training. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism
Treatment Approaches. Elmsford, NY: Pergamon Press, 1989. pp. 206-221.
Chaney, E.F.; Roszell, D.K.; and Cummings, C. Relapse in opiate addicts: A behavioral analysis.
Addictive Behaviors 7(3):291-297, 1982.
Chapman, P.L., and Huygens, I. An evaluation of three treatment programmes for alcoholism: An
experimental study with 6- and 8-month follow-ups. British journal of Addiction
83(1):67-81,1988.
http://www.freepsychotherapybooks.org
474
Chermack, S.T.; Blow, F.C.; Hill, E.M.; and Mudd, S.A. The relationship between alcohol symptoms
and consumption among older drinkers. Alcoholism: Clinical and Experimental
Research 20(7):1153-1158,1996.
Chiauzzi, E.J. Preventing Relapse in the Addictions: A Biopsychosocial Approach. New York:
Pergamon Press, 1991.
Chick, J.; Lloyd, G.; and Crombie, E. Counseling problem drinkers in medical wards: A controlled
study. British Medical journal 290:965-967,1985.
Childress, A.R.; Ehrman, R.; McLellan, A.T.; MacRae, J.; Natale, M.; and O'Brien, C.P. Can induced
moods trigger drug-related responses in opiate abuse patients? Journal of
Substance Abuse Treatment 11(1):1723,1994.
Childress, A.R.; McLellan, A.T.; Ehrman, R.; and O'Brien, C.P. Classically conditioned responses in
opioid and cocaine dependence: A role in relapse? In: Ray, B.A. Learning Factors in
Substance Abuse. NIDA Research Monograph Series, Number 84. DHHS Pub. No.
(ADM) 88-1576. Rockville, MD: National Institute on Drug Abuse, 1988. pp. 25-43.
Chinen, A.B. The emergence of transpersonal psychiatry. In: Scotton, B.W.; Chinen, A.B.; and
Battista, J.R., eds. Textbook of Transpersonal Psychiatry and Psychology. New York:
Basic Books, 1996. pp. 9-18.
Chopra, D. Overcoming Addiction: The Spiritual Solution. New York: Harmony Books, 1997.
Chutuape, M.A.; Silverman, K.; and Stitzer, M.L. Use of methadone take-home contingencies with
persistent opiate and cocaine abusers. journal of Substance Abuse Treatment
16(1):23-30,1999.
Connors, G.J.; Carroll, K.M.; DiClemente, C.C.; Longabaugh, R.; and Donovan, D.M. The therapeutic
alliance and its relationship to alcoholism treatment participation and outcome.
Journal of Consulting and Clinical Psychology 65(4):588-598,1997.
Coon, G.M.; Pena, D.; and Illich, P.A. Self-efficacy and substance abuse: Assessment using a brief
phone interview. Journal of Substance Abuse Treatment 15(5): 385-391, 1998.
475
Cooper, J.F. A Primer of Brief Psychotherapy. New York: W.W. Norton, 1995. pp. 13-34.
Cooper, J.F. Brief therapy in clinical psychology. In: Cullari, S., ed. Foundations of Clinical
Psychology. Boston: Allyn and Bacon, 1998. pp. 185-207.
Copans, S. The invisible family member: Children in families with alcohol abuse. In: CombrinckGraham, L., ed. Children in Family Contexts: Perspectives on Treatment. New York:
Guilford Press, 1988. pp. 277-298.
Corey, G. Theory and Practice of Counseling and Psychotherapy, 4th ed. Pacific Grove, CA:
Brooks/Cole, 1991.
Coudert, J. The Alcoholic in Your Life. New York: Stein and Day, 1972.
Covington, S.S. Women, addiction, and sexuality. In: Straussner, S., and Zelvin, E., eds. Gender and
Addictions: Men and Women in Treatment. Northvale, NJ: Jason Aronson, 1997.
Crawley, B. Self-medication and the elderly. In: Freeman, E.M., ed. Substance Abuse Treatment: A
Family Systems Perspective. Sage Sourcebooks for the Human Services Series, Vol.
25. Newbury Park, CA: Sage Publications, 1993. pp. 217-238.
Crits-Christoph, P. The efficacy of brief dynamic psychotherapy: A meta-analysis. American
journal of Psychiatry 149(2):151158, 1992.
Crits-Christoph, P., and Barber, J.P., eds. Handbook of Short-Term Dynamic Psychotherapy. New
York: Basic Books, 1991.
Crits-Christoph, P.; Barber, J.P.; and Kurcias, J.S. Introduction and historical background. In: CritsChristoph, P., and Barber, J.P., eds. Handbook of Short-Term Dynamic Psychotherapy.
New York: Basic Books, 1991. pp. 1-16.
Crits-Christoph, P.; Siqueland, L.; Blaine, J.; Frank, A.; Luborsky, L.; Onken, L.S.; Muenz, L.; Thase,
M.E.; Weiss, R.D.; Gastfriend, D.R.; Woody, G.; Barber, J.P.; Butler, S.F.; Daley, D.;
Bishop, S.; Najavits, L.M.; Lis, J.; Mercer, D.; Griffin, M.L.; Moras, K.; and Beck, AT.
The National Institute on Drug Abuse Collaborative Cocaine Treatment Study:
Rationale and methods. Archives of General Psychiatry 54:721-726,1997.
http://www.freepsychotherapybooks.org
476
Crits-Christoph, P.; Siqueland, L.; Blaine, J.; Frank, A.; Luborsky, L.; Onken, L.S.; Muenz, L.R.; Thase,
M.E.; Weiss, R.D.; Gastfriend, R.; Woody, G.; Barber, J.P.; Butler, S.F.; Daley, D.;
Salloum, I.; Bishop, S.; Najavits, L.M.; Lis, J.; Mercer, D.; Griffin, M.L.; Moras, K.; and
Beck, A.T. Psychosocial treatments for cocaine dependence: National Institute on
Drug Abuse Collaborative Cocaine Treatment Study. Archives of General Psychiatry
56(6):493-502, 1999.
Crowley, T.J. Contingency contracting treatment of drug-abusing physicians, nurses, and dentists.
In: Grabowski, J.; Stitzer, M.L.; and Henningfield, J.E., eds. Behavioral Intervention
Techniques in Drug Abuse Treatment. NIDA Research Monograph Series, Number
46. DHHS Pub. No. (ADM) 84-1282. Rockville, MD: National Institute on Drug
Abuse, 1984. pp. 68-83.
Cullari, S. Brief psychodynamic approaches. In: Cullari, S. ed. Foundations of Clinical Psychology.
Boston: Allyn and Bacon, 1998.
Cummings, C., and Gordon, J.R. Relapse: Strategies of prevention and prediction. In: Miller, W.R.,
ed. The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking and
Obesity. Elmsford, NY: Pergamon Press, 1980. pp. 291-321.
Cummings, N.A. Brief intermittent psychotherapy throughout the life cycle. In: Zeig, J.K., and
Gilligan, S.G., eds. Brief Therapy: Myths, Methods, and Metaphors. New York:
Brunner/Mazel, 1990. pp. 169-184.
Daily, S.G. Alcohol, incest, and adolescence. In: Lawson, G.W., and Lawson, A.W., eds. Adolescent
Substance Abuse: Etiology, Treatment, and Prevention. Gaithersburg, MD: Aspen
Publishers, 1992. pp. 251-266.
Darkes, J., and Goldman, M.S. Expectancy challenge and drinking reduction: Experimental
evidence for a mediational process, journal of Consulting and Clinical Psychology
61(2):344-353,1993.
Davanloo, H., ed. Short-Term Dynamic Psychotherapy. New York: Jason Aronson, 1980.
Davies, J.B. The Myth of Addiction: An Application of the Psychological Theory of Attribution to Illicit
Drug Use. Philadelphia: Harwood Academic Publishers, 1992.
477
Davis, D.I.; Berenson, D.; Steinglass, P.; and Davis, S. The adaptive consequences of drinking.
Psychiatry 37:209-215,1974.
DeNelsky, G.Y., and Boat, B.W. A coping skills model of psychological diagnosis and treatment.
Professional Psychology: Research and Practice 17:322-330,1986.
Denoff, M.S. An integrated analysis of the contribution made by irrational beliefs and parental
interaction to adolescent drug abuse. International Journal of the Addictions
23(7):655-659,1988.
DiClemente, C.C.; Carbonari, J.P.; Montgomery, R.P.; and Hughes, S.O. The Alcohol Abstinence SelfEfficacy Scale, journal of Studies on Alcohol 55(2): 141-148,1994.
DiClemente, C.C., and Fairhurst, S.K. Self-efficacy and addictive behaviors. In: Maddux, J.E., ed. SelfEfficacy, Adaptation, and Adjustment: Theory, Research, and Application. New York:
Plenum Press, 1995. pp. 109-141.
DiClemente, C.C.; Prochaska, J.O.; Fairhurst, S.K.; Velicer, W.F.; Velasquez, M.M.; and Rossi, J.S. The
process of smoking cessation: An analysis of precontemplation, contemplation, and
preparation stages of change, journal of Consulting and Clinical Psychology
59(2):295-304,1991.
DiClemente, C.C., and Scott, C.W. Stages of change: Interactions with treatment compliance and
involvement. In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds.. Beyond the
Therapeutic Alliance: Keeping the Drug-Dependent Individual in Treatment. NIDA
Research Monograph Series, Number 165. NIH Pub. No. 97-4142. Rockville, MD:
National Institute on Drug Abuse, 1997. pp. 131-156.
Dolan, M.P.; Black, J.L.; Penk, W.E.; Rabinowitz, R.; and DeFord, H.A. Predicting the outcome of
contingency contracting for drug abuse. Behavior Therapy 17:470-474, 1986.
Donovan, D.M. Assessment issues and domains in the prediction of relapse. Addiction
91(Suppl.):S29-S36,1996.
Donovan, D.M. Assessment and interviewing strategies in addictive behaviors. In: McCrady, B.S.,
and Epstein, E.E., eds. Addictions: A Comprehensive Guidebook for Practitioners. New
York: Oxford University Press, 1999. pp. 187-215.
http://www.freepsychotherapybooks.org
478
Donovan, D.M., and Chaney, E.F. Alcoholic relapse prevention and intervention: Models and
methods. In: Marlatt, G.A., and Gordon, J.R., eds. Relapse Prevention: Maintenance
Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press, 1985.
pp. 351-416.
Donovan, D.M., and Marlatt, G.A. Assessment of Addictive Behaviors. New York: Guilford Press,
1988.
Donovan, D.M., and Marlatt, G.A. Recent developments in alcoholism: Behavioral treatment.
Recent Developments in Alcoholism 11:397-411,1993.
Dossman, R.; Kutter, P.; Heinzel, R.; and Wurmser, L. The long-term benefits of intensive
psychotherapy: A view from Germany. In: Lazar, S.G., ed. Extended Dynamic
Psychotherapy: Making the Case in an Era of Managed Care. Hillsdale, NJ: Analytic
Press, 1997. pp. 74-86.
Douglas, L.J. "Perceived family dynamics of cocaine abusers, as compared to opiate abusers and
non-drug abusers." Ph.D. diss., University of Florida at Gainesville, 1987.
Drummond, D.C. Alcohol interventions: Do the best things come in small packages? Addiction
92(4):375-379,1997.
Drummond, D.C.; Thom, B.; Brown, C.; Edwards, G.; and Mullan, M.J. Specialist versus general
practitioner treatment of problem drinkers. Lancet 336(8720):915-918, 1990.
Edwards, G., and Orford, J. A plain treatment for alcoholism. Proceedings of the Royal Society of
Medicine 70:344-348, 1977.
Edwards, G.; Orford, J.; Egert, S.; Guthrie, S.; Hawker, A.; Hensman, C.; Mitcheson, M.;
Oppenheimer, E.; and Taylor, C. Alcoholism: A controlled trial of "treatment" and
"advice." Journal of Studies on Alcohol 38(5):1004-1031,1977.
Edwards, M.E., and Steinglass, P. Family therapy treatment outcomes for alcoholism. journal of
Marital and Family Therapy 21(4):475-509,1995.
Ehrman, R.N.; Robbins, S.J.; Childress, A.R.; and O'Brien, C.P. Conditioned responses to cocaine-
479
http://www.freepsychotherapybooks.org
480
481
Folkman, S., and Lazarus, R.S. Coping as a mediator of emotion. Journal of Personality and Social
Psychology 54(3):466-475,1988.
Folkman, S., and Lazarus, R.S. Coping and emotion. In: Monat, A., and Lazarus, R.S., eds. Stress and
Coping: An Anthology. New York: Columbia University Press, 1991. pp. 207-227.
Frankel, A.J. Groupwork with recovering families in concurrent parent and children's groups.
Alcoholism Treatment Quarterly 9(3-4):23-37,1992.
Frawley, P.J., and Smith, J.W. Chemical aversion therapy in the treatment of cocaine dependence
as part of a multimodal treatment program: Treatment outcome. Journal of
Substance Abuse Treatment 7(1):21-29,1990.
Freeman, A.; Pretzer, J.M.; Fleming, B.; Simon, K.M. Clinical Applications of Cognitive Therapy. New
York: Plenum Press, 1990.
Freeman, A., and Reinecke, M.A. Cognitive Therapy of Suicidal Behavior: A Manual for Treatment.
New York: Springer Publishing, 1993.
French, S. Family approaches to alcoholism: Why the lack of interest among marriage and family
professionals? Journal of Drug Issues 17(4):359-368,1987.
Friedberg, L.M. Psychotherapy Works: A Review of "The Effectiveness of Psychotherapy: The
Consumer Reports Study." Ann Arbor, MI: Michigan Psychological Association, 1999.
http://www.michpsych.org /worksOl.htm [Accessed June 15,1999].
Friedman, A.S. Family therapy versus parent groups: Effects on adolescent drug abusers. In:
Friedman, A.S., and Granick, S., eds. Family Therapy for Adolescent Drug Abuse.
Lexington, MA: Lexington Books, 1990. pp. 201-215.
Fromme, K.; Stroot, E.; and Kaplan, D. Comprehensive effects of alcohol: Development and
psychometric assessment of a new expectancy questionnaire. Psychological
Assessment 5(1 ):1926,1993.
Gabbard, G.O.; Lazar, S.G.; Hornberger, J.; and Spiegel, D. The economic impact of psychotherapy:
A review. American Journal of Psychiatry 154:147-155,1997.
http://www.freepsychotherapybooks.org
482
Galanter, M. Network Therapy for Alcohol and Drug Abuse: A Neiv Approach in Practice. New York:
Basic Books, 1993.
Galanter, M.; Keller, D.S.; and Dermatis, H. Network Therapy for addiction: Assessment of the
clinical outcome of training. American Journal of Drug and Alcohol Abuse 23(3):355367,1997.
Gambrill, E. A behavioral perspective of families. In: Tolson, E.R., and Reid, W.J., eds. Models of
Family Treatment. New York: Columbia University Press, 1981.
Garvin, C.D.; Reid, W.; and Epstein, L. A task-centered approach. In: Roberts, W.R., and Northen,
H., eds. Theories of Social Work With Groups. New York: Columbia University Press,
1976. pp. 238-251.
Gerstein, D.R., and Harwood, J.H., eds. Treating Drug Problems. Vol. 1. Washington, DC: National
Academy Press, 1990. pp. 40-57.
Giorgi, A., ed. Phenomenology and Psychological Research. Pittsburgh, PA: Duquesne University
Press, 1985.
Giorlando, M., and Schilling, R.J. On becoming a solution-focused physician: The MED-STAT
acronym. Families, Systems and Health 14(4): 361-371,1996.
Goldman, M.S. The alcohol expectancy concept: Applications to assessment, prevention, and
treatment of alcohol abuse. Applied and Preventive Psychology 3(3):131-144,1994.
Goldman, M.S., and Brown, S.A. Expectancy theory: Thinking about drinking. In: Blane, T., and
Leonard, K.E., eds. Psychological Theories of Drinking and Alcoholism. New York:
Guilford Press, 1987. pp. 181-226.
Goldman, M.S., and Rather, B.C. Substance abuse disorders: Cognitive models and architecture. In:
Kendall, P.C., and Dobson, K.S., eds. Psychopathology and Cognition. San Diego, CA:
Academic Press, 1993. pp. 245-292.
Gomberg, E.S. Women and alcohol: Use and abuse. Journal of Nervous and Mental Disease 181(4):
211-219,1993.
483
Gomberg, E.S.; Nelson, B.W.; and Hatchett, B.F. Women, alcoholism, and family therapy. Family
and Community Health 13(4):6171, 1991.
Gorad, S.L.; McCourt, W.F.; and Cobb, J.C. A communications approach to alcoholism. Quarterly
Journal of Studies on Alcohol 32:651 668,1971.
Gottheil, E.; Weinstein, S.P.; Sterling, R.C.; Lundy, A.; and Serota, R.D. A randomized controlled
study of the effectiveness of intensive outpatient treatment for cocaine
dependence. Psychiatric Services 49(6):782-787,1998.
Grenyer, B.F.; Luborsky, L.; and Solowij, N. Treatment Manual for Supportive-Expressive Dynamic
Therapy: Special Adaptation for Treatment of Cannabis (Marijuana) Dependence.
Technical Report 26. Sydney, Australia: National Drug and Alcohol Research
Center, 1995.
Grenyer, B.F.; Solowij, N.; and Peters, R. "Psychotherapy for marijuana addiction: A randomized
controlled trial of brief versus intensive treatment." Paper presented at the
conference of the Society for Psychotherapy Research, Amelia Island, FL, 1996.
Grof, S. Beyond the Brain: Birth, Death, and Transcendence in Psychotherapy. Albany, NY: State
University of New York Press, 1985.
Hales, R.E.; Yudofsky, S.C.; and Talbott, J.A., eds. The American Psychiatric Press Textbook of
Psychiatry, 2nd ed. Washington, DC: American Psychiatric Press, 1994.
Haley, J. Strategies of Psychotherapy. New York: Grune and Stratton, 1963.
Haley, J. Uncommon Therapy: The Psychiatric Techniques of Milton Erickson, M.D. New York: W.W.
Norton, 1973.
Haley, J. Problem-Solving Therapy: New Strategies for Effective Family Therapy. San Francisco:
Jossey-Bass, 1976.
Haley, J. Problem-solving Therapy, 2nd ed. San Francisco: Jossey-Bass, 1987.
Harris, K.B., and Miller, W.R. Behavioral self-control training for problem drinkers: Components
http://www.freepsychotherapybooks.org
484
485
Higgins, S.T. The influence of alternative reinforcers on cocaine use and abuse: A brief review.
Pharmacological and Biochemical Behaviors 57(3):419-427,1997.
Higgins, S.T. Potential contributions of the community reinforcement approach and contingency
management to broadening the base of substance abuse treatment. In: Tucker, J.A.;
Donovan, D.M.; and Marlatt, G.A., eds. Changing Addictive Behavior: Bridging Clinical
and Public Health Strategies. New York: Guilford Press, 1999. pp. 283-306.
Higgins, ST.; Budney, A.J.; Bickel, W.K.; Foerg, E.; Donham, R.; and Badger, M.S. Incentives improve
outcome in outpatient behavioral treatment of cocaine dependence. Archives of
General Psychiatry 51:568-576, 1994.
Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Hughes, J.R.; Foerg, F.; and Badger, G. Achieving cocaine
abstinence with a behavioral approach. American Journal of Psychiatry 150(5):763769,1993.
Higgins, S.T.; Delaney, D.D.; Budney, A.J.; Bickel, W.K.; Hughes, J.R.; Foerg, F.; and Fenwick, J.W. A
behavioral approach to achieving initial cocaine abstinence. American Journal of
Psychiatry 148(9):1218-1224,1991.
Higgins, S.T.; Tidey, J.W.; and Stitzer, M.L. Community reinforcement and contingency
management interventions. In: Graham, A.W.; Schultz, T.K.; and Wilford, B.B., eds.
Principles of Addiction Medicine, 2nd ed. Chevy Chase, MD: American Society of
Addiction Medicine, Inc., 1998. pp. 675-690.
Higgins-Biddle, J.C.; Babor, T.F.; Mullahy, J.; Daniels, J.; and McRee, B. Alcohol screening and brief
intervention: Where research meets practice. Connecticut Medicine 61(9):565-575,
1997.
Hill, A. Treatment and prevention of alcoholism in the Native American family. In: Lawson,
W., and Lawson, A.W., eds. Alcoholism and Substance Abuse in Special Populations. Rockville, MD:
Aspen Publishers, 1989. pp. 247-272.
Hodgins, D.C.; Leigh, G.; Milne, R.; and Gerrish, R. Drinking goal selection in behavioral self
management treatment of chronic alcoholics. Addictive Behaviors 22(2):247255,1997.
http://www.freepsychotherapybooks.org
486
Hodgson, R., and Rollnick, S. How brief intervention works: Representative cases as viewed by
the health advisers. In: Babor, T.F., and Grant, M., eds. Project on Identification and
Management of Alcohol-Related Problems. Report on Phase II: A Randomized Clinical
Trial of Brief Interventions in Primary Health Care. Geneva, Switzerland: World
Health Organization, 1991. pp. 221 232.
Holder, H.; Longabaugh, R.; Miller, W.R.; and Rubonis, A.V. The cost effectiveness of treatment for
alcoholism: A first approximation. Journal of Studies on Alcohol 52(6):517540,1991.
Hollon, S.D., and Beck, A.T. Cognitive and cognitive-behavioral therapies. In: Bergin, E., and
Garfield, S.L., eds. Handbook of Psychotherapy and Behavior Change, 4th ed. New
York: John Wiley and Sons, 1994. pp. 428-466.
Horowitz, M.J. Short-term dynamic therapy of stress response syndromes. In: Crits-Christoph, P.,
and J.P. Barber, eds. Handbook of Short-Term Dynamic Psychotherapy. New York:
Basic Books, 1991. pp. 166-198.
Horvath, A.O., and Greenberg, L.S., eds. The Working Alliance: Theory, Research, and Practice. New
York: John Wiley and Sons, 1994.
Howard, M.O.; Elkins, R.L.; Rimmele, C.; and Smith, J.W. Chemical aversion treatment of alcohol
dependence. Drug and Alcohol Dependence 29(2):107-143,1991.
Hoyt, M.F. Brief Therapy and Managed Care: Readings for Contemporary Practice. San Francisco:
Jossey-Bass, 1995.
Hser, Y.I.; Joshi, V.; Anglin, M.D.; and Fletcher, Predicting posttreatment cocaine abstinence for
first-time admissions and treatment repeaters. American journal of Public Health
89(5):666-671, 1999.
Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, J.; and Etheridge, R.M. Overview of 1-year
outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of
Addictive Behaviors 11(4):261-278,1997.
Hunt, G.M., and Azrin, N.H. A community-reinforcement approach to alcoholism. Behaviour
Research and Therapy 11(1 ):91104,1973.
487
ICD-9-CM: The International Classification of Diseases, 9th Revision, Clinical Modification. New
York: McGraw-Hill, 1995.
Iguchi, M.Y.; Belding, M.A.; Morral, A.R.; Lamb, R.J.; Husband, S.D. Reinforcing operants other than
abstinence in drug abuse treatment: An effective alternative for reducing drug use.
Journal of Consulting and Clinical Psychology 65(3):421-428,1997.
Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC:
National Academy Press, 1990.
Institute of Medicine. Pathways of Addiction: Opportunities in Drug Abuse Research. Committee on
Opportunities in Drug Abuse Research. Washington, DC: National Academy Press,
1996.
Jackson, J. The adjustment of the family to the crisis of alcoholism. Quarterly Journal of Studies on
Alcohol 15:562-586,1954.
Jaffe, A.J., and Kilbey, M.M. The Cocaine Expectancy Questionnaire (CEQ): Construction and
predictive utility. Psychological Assessment 6(1 ):1826, 1994.
Janis, I.L., and Mann, L. Decision Making: /4 Psychological Analysis of Conflict, Choice, and
Commitment. New York: Free Press, 1977.
Jarvis, T.J. Implications of gender for alcohol treatment research: A quantitative and qualitative
review. British Journal of Addiction 87(9):1249-1261, 1992.
Jesse, R.C. Children in Recovery. New York: W.W. Norton, 1989.
Johnson, R. Ecstasy: Understanding the Psychology of Joy. San Francisco: Harper & Row, 1987.
Johnson, V.E. I'll Quit Tomorrow. New York: Harper & Row, 1973.
Johnson, V.E. Intervention: How To Help Someone Who Doesn't Want Help: A Step-by-Step Guide for
Families and Friends of Chemically Dependent Persons. Minneapolis, MN: Johnson
Institute Books, 1986.
http://www.freepsychotherapybooks.org
488
Jones, B.T., and McMahon, J. Negative alcohol expectancy predicts post-treatment abstinence
survivorship: The whether, when and why of relapse to a first drink. Addiction
89(12):1653-1665, 1994a.
Jones, B.T., and McMahon, J. Negative and positive alcohol expectancies as predictors of
abstinence after discharge from a residential treatment program: A one-month and
three-month follow-up study in men. Journal of Studies on Alcohol 55(5):543-548,
1994b.
Jones, B.T., and McMahon, J. A comparison of positive and negative alcohol expectancy and value
and their multiplicative composite as predictors of post-treatment abstinence
survivorship. Addiction 91 (1 ):8999, 1996.
Jones, B.T., and McMahon, J. Alcohol motivations as outcome expectancies. In: Miller, W.R., and
Heather, N., eds. Treating Addictive Behaviors, 2nd ed. New York: Plenum Press,
1998. pp. 75-91.
Juhnke, G.A., and Coker, J.K. Solution-focused intervention with recovering, alcohol-dependent,
single parent mothers and their children. Journal of Addictions and Offender
Counseling 17(2):77-87,1997.
Kadden, R.; Carroll, K.; Donovan, D.; Cooney, N.; Monti, P.; Abrams, D.; Litt, M.; and Hester, R., eds.
Cognitive-Behavioral Coping Skills Therapy Manual: A Clinical Research Guide for
Therapists Treating Individuals With Alcohol Abuse and Dependence. Project MATCH
Monograph Series, Volume 3. Rockville, MD: National Institute on Alcohol Abuse
and Alcoholism, 1992.
Kahan, M.; Wilson, L.; and Becker, L. Effectiveness of physician-based interventions with problem
drinkers: A review. Canadian Medical Association Journal 152(6):851-859,1995.
Kang, S.Y.; Kleinman, P.H.; Woody, G.E.; Millman, R.B.; Todd, T.C.; Kemp, J.; and Lipton, D.S.
Outcomes for cocaine abusers after once-a-week psychosocial therapy. American
Journal of Psychiatry 148(5):630-635, 1991.
Kaplan, H., and Sadock, B., eds. Comprehensive Textbook of Psychiatry, 6th ed. Vol. 2. Baltimore,
MD: Williams and Wilkins, 1995.
489
Katz, R. The Straight Path: A Story of Healing and Transformation in Fiji. Reading, MA: AddisonWesley, 1993.
Kaufman, E., and Borders, L. Ethnic family differences in adolescent substance use. In: Coombs,
R.H., ed. Family Context of Adolescent Drug Use. New York: Haworth Press, 1988. pp.
99-121.
Kaufman, E., and Kaufmann, P. From multiple family therapy to couples therapy. In: Kaufman E.,
and Kaufmann, P., eds. Family Therapy of Drug and Alcohol Abuse. New York:
Gardner Press, 1979.
Kay, J. Brief psychodynamic psychotherapies: Past, present, and future challenges. Journal of
Psychotherapy Practice and Research 6(4):330-337,1997.
Keller, D.S.; Galanter, M.; and Weinberg, S. Validation of a scale for network therapy: A technique
for systematic use of peer and family support in addiction treatment. American
Journal of Drug and Alcohol Abuse 23(1):115127, 1997.
Kendall, P.C., and Turk, D.C. Cognitive-behavioral strategies and health enhancement. In:
Matarazzo, J.D.; Weiss, S.M.; and Herd, J.A., eds. Behavioral Health: A Handbook of
Health Enhancement and Disease Prevention. New York: John Wiley and Sons, 1984.
pp. 393-405.
Khantzian, E.J. The self-medication hypothesis of addictive disorders: Focus on heroin and
cocaine dependence. American Journal of Psychiatry 142(11):1259-1264,1985.
Khantzian, E.J.; Halliday, K.S.; and McAuliffe, W.E. Addiction and the Vulnerable Self: Modified
Dynamic Group Therapy for Substance Abusers. New York : Guilford Press, 1990.
Kirby, K.C.; Marlowe, D.B.; Festinger, D.S.; Lamb, R.J.; and Platt, J.J. Schedule of voucher delivery
influences initiation of cocaine abstinence. Journal of Consulting and Clinical
Psychology 66:761-767,1998.
Kirmil-Gray, K.; Eagleston, J.R.; Thoresen, C.E.; and Zarcone, V.P., Jr. Brief consultation and stress
management treatments for drug-dependent insomnia: Effects on sleep quality,
self-efficacy, and daytime stress. Journal of Behavioral Medicine 8(l):79-99,1985.
http://www.freepsychotherapybooks.org
490
Kleber, H.D., and Gawin, F.H. Cocaine abuse: A review of current and experimental treatments. In:
Grabowski, J., ed. Cocaine: Pharmacology, Effects, and Treatment of Abuse. NIDA
Research Monograph Series, Number 50. DHHS Pub. No. (ADM) 84-1326. Rockville,
MD: National Institute on Drug Abuse, 1984. pp. 111-129.
Kleinman, P.H.; Woody, G.E.; Todd, T.C.; Millman, R.B.; Kang, S.; Kemp, J.; and Lipton, D.S. Crack
and cocaine abusers in outpatient psychotherapy. In: Onken, L.S., and Blaine, J.D.,
eds. Psychotherapy and Counseling in the Treatment of Drug Abuse. NIDA Research
Monograph Series, Number 104. DHHS Pub. No. (ADM) 90-1722. Rockville, MD:
National Institute on Drug Abuse, 1990. pp. 24-35.
Klerman, G.L., and Weissman, M.M., eds. New Applications of Interpersonal Psychotherapy.
Washington, DC: American Psychiatric Press, 1993.
Klerman, G.L.; Weissman, M.M.; and Rounsaville, B.J. Interpersonal Psychotherapy of Depression.
New York: Basic Books, 1984.
Koss, M.P.; Butcher, J.N.; and Strupp, H.H. Brief psychotherapy methods in clinical research.
Journal of Consulting and Clinical Psychology 54:60-67,1986.
Koss, M.P., and Shiang, J. Research on brief psychotherapy. In: Bergin, A.E., and Garfield, S.L., eds.
Handbook of Psychotherapy and Behavior Change, 4th ed. New York: John Wiley and
Sons, 1994. pp. 664-700.
Krampen, G. Motivation in the treatment of alcoholism. Addictive Behaviors 14:197-200, 1989.
Kristenson, H.; Ohlin, H.; Hulten-Nosslin, B.; Trell, E.; and Hood, B. Identification and intervention
of heavy drinking in middle-aged men: Results and follow-up of 24-60 months of
long-term study with randomized controls. Alcoholism: Clinical and Experimental
Research 7(2):203-209,1983.
Kristenson, H., and Osterling, A. Problems and possibilities. Addiction 89(6):671-674,1994.
Krystal, H. Aspects of affect theory. Bulletin of the Menninger Clinic 41:1-26,1977.
Kymissis, P.; Bevacqua, A.; and Morales, N. Multi-family group therapy with dually diagnosed
491
http://www.freepsychotherapybooks.org
492
Levin, J.D. Treatment of Alcoholism and Other Addictions: A Self Psychology Approach. Northvale,
NJ: Jason Aronson, 1987.
Levine, B. Fundamentals of Group Treatment. Chicago: Whitehall, 1967.
Levine, B., and Gallogly, V. Group Therapy With Alcoholics: Outpatient and Inpatient Approaches.
Sage Human Services Guides, Number 40. Beverly Hills, CA: Sage Publications,
1985.
Lewinsohn, P.M.; Clarke, G.N.; Hops, H.; and Andrews, J.A. Cognitive-behavioral treatment for
depressed adolescents. Behavior Therapy 21:385-401,1990.
Lewis, M.L. Alcoholism and family casework. Social Casework 35:8-14,1937.
Liddle, H.A., and Dakof, G.A. "Effectiveness of family-based treatments for adolescent substance
abuse." Paper presented at the Annual Meeting of the Society for Psychotherapy
Research, Santa Fe, NM, 1994.
Liddle, H.A., and Dakof, G.A. Efficacy of family therapy for drug abuse: Promising but not
definitive. Journal of Marital and Family Therapy 21 (4):511543, 1995.
Liddle, H.A.; Dakof, G.; Diamond, G.; Holt, M.; Aroyo, J.; and Watson, M. The adolescent module in
multidimensional family therapy. In: Lawson, G.W., and Lawson, A.W., eds.
Adolescent Substance Abuse: Etiology, Treatment, and Prevention. Gaithersburg, MD:
Aspen Publishers, 1992. pp. 165-186.
Linehan, M.M. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York:
Guilford Press, 1993.
Litman, G.K. Alcohol survival: The prevention of relapse. In: Miller, W.R., and Heather, N., eds.
Treating Addictive Behaviors: Processes of Change. New York: Plenum Press, 1986.
pp. 391-405.
Locke, H., and Wallace, K. Short marital adjustment and prediction tests: Their reliability and
validity. Marriage and Family Living 21:251-255,1959.
493
Lowinson, J.H.; Ruiz, P.; and Millman, R.B. Substance Abuse: A Comprehensive Textbook, 3rd ed.
Baltimore: Williams & Wilkins, 1997.
Luborsky, L. Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive
Treatment. New York: Basic Books, 1984.
Luborsky, L., and Mark, D. Short-term supportive-expressive psychoanalytic psychotherapy. In:
Crits-Christoph, P., and Barber, J.P., eds. Handbook of Short-Term Dynamic
Psychotherapy. New York: Basic Books, 1991. pp. 110-136.
Luborsky, L.; McLellan, T.A.; Woody, G.E.; O'Brien, C.P.; and Auerbach, A. Therapist success and its
determinants. Archives of General Psychiatry 42:602-611,1985.
Luborsky, L.; Woody, G.E.; Hole, A.V.; and Velleco, A. "Manual for supportive-expressive dynamic
psychotherapy: A special version for drug dependence." Unpublished manuscript,
University of Pennsylvania, 1977, rev. ed. 1989.
Luborsky, L.; Woody, G.E.; Hole, A.V.; and Velleco, A. Supportive-expressive dynamic therapy for
the treatment of opiate drug dependence. In: Barber, J.P., and Crits-Christoph, P.,
eds. Dynamic Therapies for Psychiatric Disorders: Axis I. New York: Basic Books,
1995. pp. 131-160.
Lyons, L.C., and Woods, P.J. The efficacy of rational-emotive therapy: A quantitative review of the
outcome research. Clinical Psychology Review 11:357-369,1991.
Lyotard, J.F. The Post-Modern Condition: A Report on Knowledge. Minneapolis, MN: University of
Minnesota Press, 1984.
Mackay, P.W., and Donovan, D.M. Cognitive and behavioral approaches to alcohol abuse. In:
Frances, R.J., and Miller, S.I., eds. Clinical Textbook of Addictive Disorders. New York:
Guilford Press, 1991. pp. 452-481.
MacKenzie, R.K. Introduction to Time-Limited Group Psychotherapy. Washington, DC: American
Psychiatric Press, 1990.
Magura, S.; Casriel, C.; Goldsmith, D.S.; and Lipton, D.S. Contracting with clients in methadone
http://www.freepsychotherapybooks.org
494
495
Mark, D., and Faude, J. Psychotherapy of Cocaine Addiction: Entering the Interpersonal World of the
Cocaine Addict. Northvale, NJ: Jason Aronson, 1997.
Mark, D., and Luborsky, L. "A manual for the use of supportive-expressive psychotherapy in the
treatment of cocaine abuse." Unpublished manuscript, University of Pennsylvania,
1992.
Marlatt, G.A. Craving for alcohol, loss of control and relapse: A cognitive behavioral analysis. In:
Nathan, P.E.; Marlatt, G.A.; and Leberg, T., eds. Alcoholism: New Directions in
Behavioral Research and Treatment. New York: Plenum Press, 1978.
Marlatt, G.A. Section I: Theoretical perspectives on relapse. Taxonomy of high-risk situations for
alcohol relapse: Evolution and development of a cognitive-behavioral model.
Addiction 91(Suppl.):S37-S49, 1996.
Marlatt, G.A.; Baer, J.S.; Donovan, D.M.; and Kivlahan, D.R. Addictive behaviors: Etiology and
treatment. Annual Review of Psychology 39:223-252,1988.
Marlatt, G.A., and Donovan, D.M. Alcoholism and drug dependence: Cognitive social learning
factors in addictive behaviors. In: Craighead, W.E.; Mahoney, M.J.; and Kazdin, A.E.,
eds. Behavior Modification: Principles, Issues, and Applications, 2nd ed. Boston:
Houghton Mifflin, 1981. pp. 264-285.
Marlatt, G.A., and Gordon, J.R. Determinants of relapse: Implications for the maintenance of
behavior change. In: Davidson, P., and Davidson, S.M., eds. Behavioral Medicine:
Changing Health Lifestyles. New York, Brunner/Mazel, 1980. pp. 410-452.
Marlatt, G.A., and Gordon, J.R. Relapse Prevention: Maintenance Strategies in the Treatment of
Addictive Behaviors. New York: Guilford Press, 1985.
Marlatt, G.A.; Somers, J.M.; and Tapert, S.F. Harm reduction: Application to alcohol abuse
problems. In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds. Behavioral Treatments for
Drug Abuse and Dependence. NIDA Research Monograph Series, Number 137. NIH
Pub. No. (ADM) 93-3684. Rockville, MD: National Institute on Drug Abuse, 1993.
pp. 147-166.
Maslow, A.H. Toward a Psychology of Being, 2nd ed. Princeton, NJ: Van Nostrand, 1968.
http://www.freepsychotherapybooks.org
496
Maslow, A.H. Motivation and Personality, 3rd ed. New York: Harper & Row, 1987.
Matano, R.A., and Yalom, I.R. Approaches to chemical dependency: Chemical dependency and
interactive group therapy: A synthesis. International journal of Group
Psychotherapy 41(3):269-293, 1991.
Mattick, R.P., and Jarvis, T. Brief or minimal intervention for 'alcoholics'? The evidence suggests
otherwise. Drug and Alcohol Review 13:137-144,1994.
Maultsby, M.C. Group Leaders Guide for Rational Behavior Training. Provided for the United States
District Court, Northern District of Texas, Dallas, TX. 1976.
May, G.G. Addiction and Grace. San Francisco: Harper, 1991.
May, R., and Yalom, I. Existential psychotherapy. In: Corsini, R.J., and Wedding, D., eds. Current
Psychotherapies, 5th ed. Itasca, IL: F.E. Peacock, 1995. pp. 262-292.
McCrady, B.S. Outcomes of family-involved alcoholism treatment. In: Galanter, M., ed. Recent
Developments in Alcoholism. Vol. 7. New York: Plenum Press, 1989. pp. 165-182.
McCrady, B.S. Promising but underutilized treatment approaches. Alcohol Health & Research
World 15(3):215-218,1991.
McCrady, B.S. Relapse prevention: A couples-therapy perspective. In: O'Farrell, T. J., ed. Treating
Alcohol Problems: Marital and Family Interventions. New York: Guilford Press, pp.
327-350.
McCrady, B.S.; Noel, N.E.; Abrams, D.B.; Stout, R.L.; Nelson, H.F; and Hay, W.M. Comparative
effectiveness of three types of spouse involvement in outpatient behavioral
alcoholism treatment. Journal of Studies on Alcohol 47(6):459-467,1986.
McCrady, B.S.; Stout, R.; Noel, N.; Abrams, D.; and Nelson, H. Effectiveness of three types of
spouse-involved behavioral alcoholism treatment. British Journal of Addiction
86(11):1415-1424,1991.
McGoldrick, M.; Giordano, J.; and Pearce, J.K. Ethnicity and Family Therapy, 2nd ed. New York:
497
http://www.freepsychotherapybooks.org
498
Midanik, L. The validity of self-reported alcohol consumption and alcohol problems: A literature
review. British Journal of Addiction 77(4):357-382, 1982.
Middelkoop, P. The Wise Old Man: Healing Through Inner Images. Trans., A. Dixon. Boston:
Shambhala, 1989.
Milby, J.B.; Schumacher, J.E.; Raczynski, J.M.; Caldwell, E.; Engle, M.; Michael, M.; and Carr, J.
Sufficient conditions for effective treatment of substance abusing homeless
persons. Drug and Alcohol Dependence 43(1-2):39-47,1996.
Miller, N.S., ed. Comprehensive Handbook of Drug and Alcohol Addiction. New York: Marcel Dekker,
1991.
Miller, S.D. The resistant substance abuser: Court mandated cases can pose special problems.
Commentary: A solution-focused approach. Netivorker 16(l):83-87,1992.
Miller, S.D. Some questions (not answers) for the brief treatment of people with drug and alcohol
problems. In: Hoyt, M., ed. Constructive Therapies. New York: Guilford Press, 1994.
Miller, S.D., and Berg, I. Working with the problem drinker: A solution-focused approach. Arizona
Counseling Journal 16(1 ):312,1991.
Miller, W.R. Behavioral treatments for drug problems: Lessons from the alcohol treatment
outcome literature. In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds. Behavioral
Treatments for Drug Abuse and Dependence. NIDA Research Monograph Series,
Number 137. NIH Pub. No. (ADM) 93-3684. Rockville, MD: National Institute on
Drug Abuse, 1993. pp. 303-321.
Miller, W.R.; Benefield, R.G.; and Tonigan, J.S. Enhancing motivation for change in problem
drinking: A controlled comparison of two therapist styles. Journal of Consulting and
Clinical Psychology 61:455-461,1993.
Miller, W.R.; Brown, J.M.; Simpson, T.L.; Handmaker, N.S.; Bien, T.H.; Luckie, L.F.; Montgomery,
H.A.; Hester, R.K.; and Tonigan, J.S. What works? A methodological analysis of the
alcohol treatment outcome literature. In: Hester, R.K., and Miller, W.R., eds.
Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd ed.
Boston: Allyn and Bacon, 1995. pp. 12-44.
499
Miller, W.R.; Gribskov, C.J.; and Mortell, R.L. Effectiveness of a self-control manual for problem
drinkers with and without therapist contact. International Journal of the Addictions
16(7):1247-1254,1981.
Miller, W.R., and Hester, R.K. Inpatient alcoholism treatment: Who benefits? American
Psychologist 41(7): 794-805, 1986a.
Miller, W.R., and Hester, R.K. Treating Addictive Behaviors: Processes of Change. New York:
Plenum Press, 1986b.
Miller, W.R.; Jackson, K.A.; and Karr, K.W. Alcohol problems: There's a lot you can do in two or
three sessions. EAP Digest 14:18-21, 35-36,1994.
Miller, W.R., and Munoz, R.F. How To Control Your Drinking. Englewood Cliffs, NJ: Prentice-Hall,
1982.
Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People To Change Addictive
Behavior. New York: Guilford Press, 1991.
Miller, W.R., and Sanchez, V.C. Motivating young adults for treatment and lifestyle change. In:
Howard, G.S., and Nathan, P.E., eds. Alcohol Use and Misuse by Young Adults. Notre
Dame, IN: University of Notre Dame Press, 1994. pp. 55-82.
Miller, W.R., and Sovereign, R.G. The check-up: A model for early intervention in addictive
behaviors. In: Leberg, T.; Miller, W.R.; Nathan, P.E.; and Marlatt, G.A., eds. Addictive
Behaviors: Prevention and Early Intervention. Amsterdam: Swets and Zeitlinger,
1989. pp. 219-311.
Miller, W.R., and Taylor, C.A. Relative effectiveness of bibliotherapy, individual and group selfcontrol training in the treatment of problem drinkers. Addictive Behaviors 5:13
24.1980.
Miller, W.R.; Taylor, C.A.; and West, J.C. Focused versus broad-spectrum behavior therapy for
problem drinkers, journal of Consulting and Clinical Psychology 48(5):590601.1980.
http://www.freepsychotherapybooks.org
500
Mintz, J.; Mintz, L.I.; Arruda, M.J.; and Hwang, S.S. Treatments of depression and the functional
capacity to work. Archives of General Psychiatry 49(10):761-768,1992.
Minuchin, S. Families and Family Therapy. Cambridge, MA: Harvard University Press, 1974.
Minuchin, S., and Fishman, H.C. Family Therapy Techniques. Cambridge, MA: Harvard University
Press, 1981.
Monti, P.M.; Abrams, D.B.; Kadden, R.M.; and Cooney, N.L. Treating Alcohol Dependence: A Coping
Skills Training Guide. New York: Guilford Press, 1989.
Monti, P.M.; Gulliver, S.B.; and Myers, M.G. Social skills training for alcoholics: Assessment and
treatment. Alcohol and Alcoholism 29(6):627-637,1994.
Monti, P.M.; Rohsenow, D.J.; Colby, S.M.; and Abrams, D.B. Coping and social skills. In: Hester, R.K.,
and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective
Alternatives, 2nd ed. Boston: Allyn and Bacon, 1995. pp. 221-241.
Monti, P.M.; Rohsenow, D.J.; Michaelec, E.; Martin, R.A.; and Abrams, D.B. Brief coping skills
treatment for cocaine abuse: Substance use outcomes at three months. Addiction
92(12):17171728,1997.
Moser, A.E., and Annis, H.M. The role of coping in relapse crisis outcome: A prospective study of
treated alcoholics. Addiction 91(8):11011114, 1996.
Moyer, M.A. Achieving successful chemical dependency recovery in veteran survivors of
traumatic stress. Alcoholism Treatment Quarterly 4(4):19-34,1988.
Mudd, S.A.; Blow, F.C.; Walton, M.A.; Snedecor, S.M.; and Nord, J.L. Stages of change in elderly
substance abusers. Alcohol: Clinical and Experimental Research 19 (Suppl.):90a,
1995.
Myers, M.G.; Martin, R.A.; Rohsenow, D.J.; and Monti, P.M. The Relapse Situation Appraisal
Questionnaire: Initial psychometric characteristics and validation. Psychology of
Addictive Behaviors 10(4):237-247,1996.
501
Najavits, L.M.; Weiss, R.D.; and Liese, B.S. Group cognitive-behavioral therapy for women with
PTSD and substance use disorder, journal of Substance Abuse Treatment 13(1):13
22,1996.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). Assessing Alcohol Problems: A Guide
for Clinicians and Researchers. NIAAA Treatment Handbook Series, Number 4. NIH
Pub. No. 95-3745. Washington, DC: NIAAA, 1995.
Neidigh, L.W.; Gesten, E.L.; and Shiftman, S. Coping with the temptation to drink. Addictive
Behaviors 13(1):19,1988.
Nelson, J.E. Healing the Split: Integrating Spirit Into Our Understanding of the Mentally III. Albany,
NY: State University of New York Press, 1994.
Nezu, A.M. Efficacy of a social problem-solving therapy approach for unipolar depression. journal
of Consulting and Clinical Psychology 54(2):196-202,1986.
Nichols, M.P., and Schwartz, R.C. Family Therapy: Concepts and Methods. Boston: Allyn and Bacon,
1998.
Nicholson, T.; Higgins, W.; Turner, P.; James, S.; Stickle, F.; and Pruitt, T. The relation between
meaning in life and the occurrence of drug abuse: A retrospective study. Psychology
of Addictive Behaviors 8(l):24-28, 1994.
Nielsen, G., and Barth, K. Short-term anxiety-provoking psychotherapy. In: Crits-Christoph, P., and
Barber, J.P., eds. Handbook of Short-Term Dynamic Psychotherapy. New York: Basic
Books, 1991. pp. 45-79.
Nietzel, M.T., ed. Abnormal Psychology. Boston: Allyn and Bacon, 1998.
Noel, N., and McCrady, B. Alcohol-focused spouse involvement with behavioral marital therapy.
In: O'Farrell, T.J., ed. Treating Alcohol Problems: Marital and Family Interventions.
New York: Guilford Press, pp. 210-235.
O'Brien, C.P., and Childress, A.R. A learning model of addiction. In: O'Brien, C.P., and Jaffe, J.H., eds.
Addictive States. New York: Raven Press, 1992. pp. 157-177.
http://www.freepsychotherapybooks.org
502
O'Brien, C.P.; Childress; A.R.; McClellan, T.; and Ehrman, R. Integrating systemic cue exposure
with standard treatment in recovering drug dependent patients. Addictive
Behaviors 15(4):355-365,1990.
O'Farrell, T.J., and Bayog, R.D. Antabuse contracts for married alcoholics and their spouses: A
method to maintain antabuse ingestion and decrease conflict about drinking,
journal of Substance Abuse Treatment 3:1-8,1986.
O'Farrell, T.J.; Choquette, K.A.; Cutter, H.S.; Brown, E.D.; and McCourt, W.F. Behavioral marital
therapy with and without additional couples relapse prevention sessions for
alcoholics and their wives, journal of Studies on Alcohol 54:652-666,1993.
O'Farrell, T.J., and Cowles, K.S. Marital and family therapy. In: Hester, R.K., and Miller, W.R., eds.
Handbook of Alcoholism Treatment Approaches: Effective Alternatives. New York:
Pergamon Press, 1989. pp. 183-205.
O'Farrell, T.J.; Cutter, H.S.; and Floyd, F.J. Evaluating behavioral marital therapy for male
alcoholics: Effects on marital adjustment and communication from before to after
treatment. Behavior Therapy 16:147167,1985.
O'Malley, S.S.; Jaffe, A.J.; Chang, G.; Schottenfeld, R.S.; Meyer, R.E.; and Rounsaville, B.J. Naltrexone
and coping skills therapy for alcohol dependence: A controlled study. Archives of
General Psychiatry 49:881-887,1992.
O'Malley, S.S., and Kosten, T.R. Couples therapy with cocaine abusers. Family Therapy Collections
25:121-131,1988.
Orford, J.; Guthrie, S.; Nicholls, P.; Oppenheimer, E.; Egert, S.; and Hensman, C. Self-reported
coping behavior of wives of alcoholics and its association with drinking outcome.
Journal of Studies on Alcohol 36:1254-1267,1975.
Orford, J.; Oppenheimer, E.; and Edwards, G. Abstinence or control: The outcome for excessive
drinkers two years after consultation. Behavior Research and Therapy 14:409418,1976.
O'Sullivan, C.M. Alcoholism and abuse: The twin family secrets. In: Lawson, G.W., and Lawson,
A.W., eds. Alcoholism and Substance Abuse in Special Populations. Rockville, MD:
503
http://www.freepsychotherapybooks.org
504
Phillips, E.L., and Weiner, D.N. Short-Term Psychotherapy and Structured Behavior Change. New
York: McGraw-Hill, 1966.
Piazza, J., and DelValle, C.M. Community-based family therapy training: An example of work with
poor and minority families. Journal of Strategic and Systemic Therapies ll(2):53-69,
1992.
Pine, F. Drive, Ego, Object, and Self. New York: Basic Books, 1990.
Pinsker, H.; Rosenthal, R.; and McCullough, L. Dynamic supportive therapy. In: Crits-Christoph, P.,
and Barber, J.P., eds. Handbook of Short-Term Dynamic Psychotherapy. New York:
Basic Books, 1991. pp. 220-247.
Pollack, J.; Flegenheimer, W.; and Winston, A. Brief adaptive psychotherapy. In: Crits-Christoph,
P., and Barber, J.P., eds. Handbook of Short-Term Dynamic Psychotherapy. New York:
Basic Books, 1991. pp. 199-219.
Polster, I., and Polster, M. Gestalt Therapy Integrated: Contours of Theory and Practice. New York:
Vintage Books, 1973.
Prochaska, J.O. How do people change and how can we change to help many more people? In:
Hubble, M.A.; Duncan, B.L.; and Miller, S., eds. The Heart and Soul of Change: What
Works in Therapy. Washington, DC: American Psychological Association, 1999. pp.
227-255.
Prochaska, J.O., and DiClemente, C.C. The Transtheoretical Approach: Crossing the Traditional
Boundaries of Therapy. Homewood, IL: Dorsey/Dow Jones-Irwin, 1984.
Prochaska, J.O., and DiClemente, C.C. Toward a comprehensive model of change. In: Miller, W.R.,
and Heather, N., eds. Treating Addictive Behaviors: Processes of Change. New York:
Plenum Press, 1986. pp. 3-27.
Prochaska, J.O.; DiClemente, C.C.; and Norcross, J.C. In search of the structure of change. In: Klar,
Y.; Fischer, J.D.; Chinsky, J.M., eds. Self-Change: Social Psychological and Clinical
Perspective. New York: Springer-Verlag, pp. 87-114.
505
Prochaska, J.O.; Velicer, W.F.; Rossi, J.S.; Goldstein, M.G.; Marcus, B.H.; Rakowski, W.; Fiore, C.;
Harlow, L.L.; Redding, C.A.; and Rosenbloom, D. Stages of change and decisional
balance for 12 problem behaviors. Health Psychology 131(l):39-46,1994.
Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project
MATCH posttreatment drinking outcomes, journal of Studies on Alcohol 58(l):729,1997.
Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project
MATCH three-year drinking outcomes. Alcoholism: Clinical and Experimental
Research 22(6): 13001311,1998.
Rapp, C., and Wintersteen, R. The strengths model of case management: Results from twelve
demonstrations. Psychosocial Rehabilitation journal 13(1): 23-32,1989.
Rathbone-McCuan, E., and Hedlund,}. Older families and issues of alcohol misuse: A neglected
problem in psychotherapy. Journal of Psychotherapy and the Family 5(1-2):173184,1989.
Ratner, H., and Yandoli, D. Solution-focused brief therapy: A co-operative approach to work with
clients. In: Edwards, G., and Dare, C., eds. Psychotherapy, Psychological Treatments,
and the Addictions. Cambridge: Cambridge University Press, 1996. pp. 124-138.
Read, M.R.; Penick, E.C.; and Nickel, E.J. Treatment for dually diagnosed clients. In: Freeman, E.M.,
ed. Substance Abuse Treatment: A Family Systems Perspective. Sage Sourcebooks for
the Human Services Series, Vol. 25. Newbury Park, CA: Sage Publications, 1993. pp.
123-156.
Regan, J.M.; Connors, G.J.; O'Farrell, T.J.; and Jones, W.C. Services for the families of alcoholics: A
survey of treatment agencies in Massachusetts. Journal of Studies on Alcohol
44(6):1072-1082,1983.
Rehm, L.P.; Fuchs, C.Z.; Roth, D.M.; Kornblith, S.J.; and Romano, J.M. A comparison of self-control
and assertion skills treatments of depression. Behavior Therapy 10:429-442, 1979.
Reich, J.W., and Gutierres, S.E. Life event and treatment attributions in drug abuse and
rehabilitation. American Journal of Drug and Alcohol Abuse 131(2):73-94,1987.
http://www.freepsychotherapybooks.org
506
Reilly, P.G. Assessment and treatment of the mentally ill chemical abuser and the family. Journal
of Chemical Dependency Treatment 4(1 ):167178, 1991.
Reilly, P.M.; Sees, K.L.; Shopshire, M.S.; Hall, S.M.; Delucchi, K.L.; Tusel, D.J.; Banys, P.; Clark, H.W.;
and Piotrowski, N.A. Self-efficacy and illicit opioid use in a 180-day methadone
detoxification treatment. Journal of Consulting and Clinical Psychology 63(1 ):158
162, 1995.
Rice-Licare,J., and Delaney-McLoughlin, K. Cocaine Solutions: Help for Cocaine Abusers and Their
Families. Haworth Series in Addictions Treatment, Vol. 4. New York: Harrington
Park Press, 1990.
Rimmele, C.T.; Howard, M.O.; and Hilfrink, M.L. Aversion therapies. In: Hester, R.K., and Miller,
W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd
ed. Boston: Allyn and Bacon, 1995. pp. 134-147.
Roberts, R.W., and Northen, H. Theories of Social Work ivith Groups. New York: Columbia
University Press, 1976.
Rohsenow, D.J., and Monti, P.M. Cue exposure treatment in alcohol dependence. In: Drummond,
D.C.; Tiffany, S.T.; Glautier, S.; and Remington, R., eds. Addictive Behaviour: Cue
Exposure Theory and Practice. Chichester, UK: John Wiley and Sons, 1995. pp. 169196.
Rohsenow, D.J.; Monti, P.M.; Zwick, W.R.; Nirenberg, T.D.; Liepman, M.R.; Binkoff, J.A.; and
Abrams, D.B. Irrational beliefs, urges to drink and drinking among alcoholics.
Journal of Studies on Alcohol 50(5):461-464, 1989.
Rohsenow, D.J.; Niaura, R.S.; Childress, A.R.; Abrams, D.B.; and Monti, P.M. Cue reactivity in
addictive behaviors: Theoretical and treatment implications. International Journal
of the Addictions 25(7A-8A):957-993, 1991.
Romach, M.K., and Sellers, E.M. Alcohol dependence: Women, biology, and pharmacotherapy. In:
McCance-Katz, E.F., and Kosten, T.R., eds. New Treatments for Chemical Addictions.
Washington, DC: American Psychiatric Press, 1998. pp. 35-73.
Ross, S.M.; Miller, P.J.; Emmerson, R.Y.; and Todt, E.H. Self-efficacy, standards, and abstinence
507
http://www.freepsychotherapybooks.org
508
509
for substance dependence. In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds.
Behavioral Treatments for Drug Abuse and Dependence. NIDA Research Monograph
Series, Number 137. NIH Pub. No. (ADM) 93-3684. Rockville, MD: National Institute
on Drug Abuse, 1993. pp. 5-17.
Schutt, M. Wives of Alcoholics: From Co-Dependency to Recovery. Pompano Beach: FL: Health
Communications, 1985.
Schor, L.I. "Apperception as a primary process of the psyche: Implications for theory and
practice." Ph.D. diss., Auburn University, 1998.
Scott, E., and Anderson, P. Randomized controlled trial of general practitioner intervention in
women with excessive alcohol consumption. Drug and Alcohol Review 10:313321,1991.
Scotton, B.W.; Chinen, A.B.; and Battista, J.R., eds. Textbook of Transpersonal Psychiatry and
Psychology. New York: Basic Books, 1996.
Selekman, M. "With a little help from my friends": The use of peers in the family therapy of
adolescent substance abusers. Family Dynamics of Addiction Quarterly 1(1):69
76,1991.
Seligman, M.E. What You Can Change and What You Can't: The Complete Guide to Successful SelfImprovement. New York: Knopf, 1994.
Seligman, M.E. The effectiveness of psychotherapy: The Consumer Reports study. American
Psychologist 50(12):965-74,1995. http://www.apa.org/journals/seligman. html
[Accessed Feb. 5,1999].
Selvini-Palazzoli, M.; Boscolo, L.; Cecchin, G.; and Prata, G. Paradox and Counter-Paradox: A New
Model in the Therapy of the Family in Schizophrenic Transaction. New York: Jason
Aronson, 1978.
Shaffer, H., and Burglass, M.E., eds. Classic Contributions in the Addictions. New York:
Brunner/Mazel, 1981.
http://www.freepsychotherapybooks.org
510
Shedler, J., and Block, J. Adolescent drug use and psychological health: A longitudinal inquiry.
American Psychologist 45(5):612-630, 1990.
Shiftman, S. Maintenance and relapse: Coping with temptation. In: Nirenberg, T.D., and Maisto,
S.A., eds. Developments in the Assessment and Treatment of Addictive Behaviors.
Norwood, NJ: Ablex Publishing, 1987. pp. 353-385.
Shiftman, S. Conceptual issues in the study of relapse. In: Gossop, M., ed. Relapse and Addictive
Behaviour. London: Tavistock/ Routledge, 1989. pp. 149-179.
Sifneos, P.E. Short-Term Psychotherapy and Emotional Crisis. Cambridge, MA: Harvard University
Press, 1972.
Sifneos, P.E. Short-Term Dynamic Psychotherapy: Evaluation and Technique, 2nd ed. New York:
Plenum, 1987.
Silverman, K.; Chutuape, M.A.; Bigelow, G.E.; and Stitzer, M.L. Voucher-based reinforcement of
attendance by unemployed methadone patients in a job skills training program.
Drug and Alcohol Dependence 41(3):197-207,1996.
Silverman, K.; Higgins, S.T.; Brooner, R.K.; Montoya, I.D.; Cone, E.J.; Schuster, C.R.; and Preston,
K.L. Sustained cocaine abstinence in methadone maintenance patients through
voucher-based reinforcement therapy. Archives of General Psychiatry 53:409-415,
1996.
Silverman, K.; Wong, C.J.; Umbricht-Schneiter, A.; Montoya, I.D.; Schuster, C.R.; and Preston, K.L.
Broad beneficial effects of cocaine abstinence reinforcement among methadone
patients. Journal of Consulting and Clinical Psychology 66(5):811-824,1998.
Sisson, R.W., and Azrin, N.H. Family-member involvement to initiate and promote treatment of
problem drinkers. Journal of Behavior Therapy and Experimental Psychiatry
17(1):1521, 1986.
Sisson, R.W., and Azrin, N.H. The community reinforcement approach. In: Hester, R.K., and Miller,
W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives.
New York: Pergamon Press, 1989. pp. 242-258.
511
Sisson, R.W., and Azrin, N.H. Community reinforcement training for families: A method to get
alcoholics into treatment. In: O'Farrell, T.J., ed. Treating Alcohol Problems: Marital
and Family Interventions. New York: Guilford Press, 1993. pp. 34-53.
Sitharthan, T.; Kavanagh, D.J.; and Sayer, G. Moderating drinking by correspondence: An
evaluation of a new method of intervention. Addiction 91(3):345-355,1996.
Sitharthan, T.; Sitharthan, G.; Hough, M.J.; and Kavanagh, D.J. Cue exposure in moderation
drinking: A comparison with cognitive-behavior therapy. Journal of Consulting and
Clinical Psychology 65(5):878-882,1997.
Skinner, B.F. The operant side of behavior therapy. Journal of Behavior Therapy and Experimental
Psychiatry 19(3):171-179,1988.
Sklar, S.M.; Annis, H.M.; and Turner, N.E. Development and validation of the Drug-Taking
Confidence Questionnaire: A measure of coping self-efficacy. Addictive Behaviors
22(5):655-670,1997.
Skutle, A., and Berg, G. Training in controlled drinking for early-stage problem drinkers. British
Journal of Addiction 82(5):493-501, 1987.
Smith, C.A.; Haynes, K.N.; Lazarus, R.S.; and Pope, L.K. In search of the "hot" cognitions:
Attributions, appraisals, and their relation to emotion. Journal of Personality and
Social Psychology 65(5):916-929,1993.
Smith, J.E., and Meyers, R.J. The community reinforcement approach. In: Hester, R.K., and Miller,
W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 2nd
ed. Boston: Allyn and Bacon, 1995. pp. 251-266.
Smith, J.W., and Frawley, P.J. Treatment outcome of 600 chemically dependent patients treated in
a multimodal inpatient program including aversion therapy and pentothal
interviews. Journal of Substance Abuse Treatment 10(4):359-369,1993.
Smith, J.W.; Frawley, P.J.; and Polissar, N.L. Six- and twelve-month abstinence rates in inpatient
alcoholics treated with either faradic aversion or chemical aversion compared with
matched inpatients from a treatment registry. Journal of Addictive Diseases 16(l):524,1997.
http://www.freepsychotherapybooks.org
512
Smith, J.W.; Schmeling, G.; and Knowles, P.L. A marijuana smoking cessation clinical trial utilizing
THC-free marijuana, aversion therapy, and self-management counseling. Journal of
Substance Abuse Treatment 5(2):89-98,1988.
Smokowski, P.R., and Wodarski, J.S. Cognitive-behavioral group and family treatment of cocaine
addiction. In: The Hatherleigh Guide to Treating Substance Abuse, Part 1. The
Hatherleigh Guides Series, Vol. 7. New York: Hatherleigh Press, 1996. pp. 171
189.
Smyrinos, K.X., and Kirkby, R.J. Long-term comparison of brief versus unlimited psychodynamic
treatments with children and their parent. Journal of Consulting and Clinical
Psychology 61(6):1020-1027,1993.
Sobell, L.C., and Sobell, M.B. Self-report issues in alcohol abuse: State of the art and future
directions. Behavioral Assessment 12:91-106, 1990.
Sobell, L.C.; Sobell, M.B.; and Nirenberg, T.D. Behavioral assessment and treatment planning with
alcohol and drug abusers: A review with an emphasis on clinical application.
Clinical Psychology Review 8(l):19-54,1988.
Sobell, L.C.; Toneatto, T.; and Sobell, M.B. Behavioral assessment and treatment planning for
alcohol, tobacco, and other drug problems: Current status with an emphasis on
clinical applications. Behavior Therapy 25(4):533-580,1994.
Sobell, M.B.; Maisto, S.; Sobell, L.; Cooper, A.; Cooper, T.; and Sanders, B. Developing a prototype
for evaluating alcohol treatment effectiveness. In: Sobell, L.; Sobell, M.; and Ward E.,
eds. Evaluating Drug and Alcohol Abuse Treatment Effectiveness: Recent Advances.
New York: Pergamon Press, 1980.
Solomon, K.E., and Annis, H.M. Outcome and efficacy expectancy in the prediction of
posttreatment drinking behaviour. British Journal of Addiction 85(5):659-665,
1990.
Solomon P. The efficacy of case management services for severely mentally disabled clients.
Community Mental Health Journal 28(3):163-180,1992.
Soo-Hoo, T. Brief strategic family therapy with Chinese Americans. American Journal of Family
513
http://www.freepsychotherapybooks.org
514
515
Szapocznik, J.; Perez-Vidal, A.; Brickman, A.L.; Foote, F.H.; Santisteban, D.; Herris, O.; and Kurtines,
W.M. Engaging adolescent drug abusers and their families in treatment: A strategic
structural systems approach. journal of Consulting and Clinical Psychology
56(4):552-557,1988.
Szapocznik, J.; Rio, A.; and Kurtines, W. Brief strategic family therapy for Hispanic problem youth.
In: Beutler, L.E., and Crago, M., eds. Psychotherapy Research: An International
Review of Programmatic Studies. Washington, DC: American Psychological
Association, 1991. pp. 123-132.
Szapocznik, J.; Santisteban, D.; Rio, A.; and Perez-Vidal, A. Family effectiveness training: An
intervention to prevent drug abuse and problem behaviors in Hispanic adolescents.
Hispanic journal of Behavioral Sciences 11(1): 4-27,1989.
Thomas, E.J., and Ager, R.D. Unilateral family therapy with spouses of uncooperative alcohol
abusers. In: O'Farrell, T.J., ed. Treating Alcohol Problems: Marital and Family
Interventions. New York: Guilford Press, pp. 3-33.
Thomas, E.J.; Yoshioka, M.R.; and Ager, R.D. Spouse enabling inventory. In: Fischer, J., and
Corcoran, K., eds. Measures for Clinical Practice: A Sourcebook, 2nd ed. Vol. 1.
Couples, Families, and Children. New York: Free Press, 1994. pp. 177-178.
Todd, T.C. Structural-strategic marital therapy. In: Jacobson, N.S., and Gurman, A.S., eds. Clinical
Handbook of Marital Therapy. New York: Guilford Press, 1986. pp. 71-105.
Tucker, J.A.; Vuchinich, R.E.; and Downey, K.K Substance abuse. In: Turner, S.M.; Calhoun, K.S.; and
Adams, H.E., eds. Handbook of Clinical Behavior Therapy. New York: John Wiley and
Sons, 1981. pp. 203-223.
Turner, F.J., ed. Differential Diagnosis and Treatment in Social Work. New York: Free Press, 1976.
van Bilsen, H., and Whitehead, B. Learning controlled drug use: A case study. Behavioural and
Cognitive Psychotherapy 22(1 ):8795,1994.
Van De Riet, V.; Korb, M.P.; and Gorrell, J.J. Gestalt Therapy: An Introduction. New York: Pergamon
Press, 1980.
http://www.freepsychotherapybooks.org
516
Van Utt, G., and Burglass, M.E. The collectivist issue in client-therapist matching. In: Smith, D.E.,
ed. A Multicultural View of Drug Abuse: Proceedings of the National Drug Abuse
Conference,/ 1977. Cambridge, MA: Schenkman Pub. Co., 1978. pp. 298-304.
Velicer, W.F.; Prochaska, J.O.; Rossi, J.S.; and Snow, M.G. Assessing outcome in smoking cessation
studies. Psychological Bulletin 111 (1):2341, 1992.
Volpicelli, J.R.; Alterman, A.I.; Hayashida, M.; and O'Brien, C.P. Naltrexone in the treatment of
alcohol dependence. Archives of General Psychiatry 49(ll):876-880,1992.
Von Eckartsberg, R. Existential-phenomenology, validity, and the transpersonal ground of
psychological theorizing. In: Giorgi, A.; Barton, A.; and Maes, C., eds. Duquesne
Studies in Phenomenology, Vol. 4. Pittsburgh: Duquesne University Press, 1983. pp.
199-201.
Wallace, P.; Cutler, S.; and Haines, A. Randomised controlled trial of general intervention in
patients with excessive alcohol consumption. British Medical journal 297:663-668,
1988.
Walton, M.A.; Castro, F.G.; and Barrington, E.H. The role of attributions in abstinence, lapse, and
relapse following substance abuse treatment. Addictive Behaviors 19(3):319331,
1994.
Watzlawick, P.; Bavelas, J.B.; and Jackson, D.D. Pragmatics of Human Communication: A Study of
Interactional Patterns, Pathologies, and Paradoxes. New York: W.W. Norton, 1967.
Watzlawick, P.; Weakland, J.; and Fisch, R. Change: Principles of Problem Formation and Problem
Resolution. New York: W.W. Norton, 1974.
Weeks, G.R., and L'Abate, L. A compilation of paradoxical methods. American Journal of Family
Therapy 7:61-76,1979.
Wegscheider-Cruse, S. The Miracle of Recovery. Deerfield Beach, FL: Health Communications,
1989.
Weil, A. The Natural Mind: An Investigation of Drugs and the Higher Consciousness. Boston:
517
http://www.freepsychotherapybooks.org
518
Woody, G.E.; Luborsky, L.; McLellan, A.T.; and O'Brien, C.P. Psychotherapy for opiate dependence.
In: Ashery, R.S., ed. Progress in the Development of Cost-Effective Treatment for Drug
Abusers. NIDA Research Monograph Series, Number 58. DHHS Pub. No. (ADM) 851401. Rockville, MD: National Institute on Drug Abuse, 1985. pp. 9-29.
Woody, G.E.; Luborsky, L.; McLellan, A.T.; O'Brien, C.P.; Beck, A.T.; Blaine, J.; Herman, I.; and Hole,
A. Psychotherapy for opiate addicts: Does it help? Archives of General Psychiatry
40:639-645,1983.
Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O'Brien, C.P. Twelve-month follow-up of
psychotherapy for opiate dependence. American journal of Psychiatry 144(5):590596, 1987.
Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O'Brien, C.P. Psychotherapy and counseling for
methadone-maintained opiate addicts: Results of research studies. In: Onken, L.S.,
and Blaine, J.D., eds. Psychotherapy and Counseling in the Treatment of Drug Abuse.
NIDA Research Monograph 104. DHHS Pub. No. (ADM) 91-1722, Rockville, MD:
National Institute on Drug Abuse, 1990. pp. 9-23.
Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O'Brien, C.P. Psychotherapy in community
methadone programs: A validation study. American journal of Psychiatry
152(9):1302 1308,1995.
Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O'Brien, C.P. Psychotherapy with opioid-dependent
patients. Psychiatric Times, 15(11), 1998. http://mhsource.com/edu/psytimes/
p981159.html [Accessed August 10,1999].
Woody G.E.; Mercer D.; and Luborsky L. Psychotherapy for substance abuse. In: Michels, R., ed.
Psychiatry Series. Philadelphia, PA: J.B. Lippincott Company, 1994.
Wright, J.H., and Beck, A. Cognitive therapy. In: Hales, R.E.; Yudofsky, S.C.; and Talbott, J.A., eds.
American Psychiatric Press Textbook of Psychiatry, 2nd ed. Washington, DC:
American Psychiatric Press, 1994.
Yalom, I.D. Existential Psychotherapy. New York: Basic Books, 1980.
Yalom, I.D. The Theory and Practice of Group Psychotherapy, 4th ed. New York: Basic Books, 1995.
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Yalom, I.D. The Yalom Reader: On Writing, Living, and Practicing Psychology. New York: Basic
Books, 1997.
Zients, A. Presentation to the Mental Health Work Group, White House Task Force for National
Health Care Reform, April 23,1993.
Ziter, M.L.P. Culturally sensitive treatment of Black alcoholic families. Social Work 32(2):130135,1987.
Zitter, R., and McCrady, B.S. The Drinking Patterns Questionnaire. Unpublished questionnaire.
Piscataway, NJ: Rutgers University, 1993.
Zweben, A.; Pearlman, S.; and Li, S. A comparison of brief advice and conjoint therapy in the
treatment of alcohol abuse: The results of the Marital Systems Study. British Journal
of Addiction 83(8):899-916, 1988.
Zweben, J.E. Recovery-oriented psychotherapy: Patient resistances and therapist dilemmas.
Journal of Substance Abuse Treatment 6(2):123-132,198.
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Appendix B
Information and Training Resources
General Brief Therapy
American Psychological Association (APA)Division 29: Psychotherapy
Division of Psychotherapy
P.O. Box 638
Niwot, CO 80544-0638
Phone: (303) 652-9154
Fax: (303) 652-2723
Web site: http://www.cwru.edu/affil/div29/ div29.htm
E-mail: lpete@indra.com
APA, headquarted in Washington, DC, is the world's largest association
of psychologists. APA's membership includes more than 159,000 researchers,
educators, clinicians, consultants, and students. Through its divisions in 50
subfields of psychology and affiliations with 59 State, territorial, and
Canadian provincial associations, APA works to advance psychology as a
science, as a profession, and as a means of promoting human welfare.
Division 29 promotes education, research, high standards of practice,
and the exchange of information among psychologists interested in
psychotherapy.
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Cognitive-Behavioral Therapy
Aaron T. Beck Institute for Cognitive Studies
Edmund F. O'Reilly, Ph.D.
Founders Hall, Room 319
Assumption College
500 Salisbury Street
P.O. Box 15005
Worcester, MA 01615-0005
Phone: (508) 767-7000, x 7554
Web site: http://www.assumption.edu/
E-mail: eoreill@eve.assumption.edu
The Aaron T. Beck Institute for Cognitive Studies provides information
that highlights the contributions of cognitive factors to the resolution of
problems in living. The Institute hosts annual speakers and conferences that
address research and therapeutic development in cognitive therapy as well as
ethical and moral issues. It also sponsors education and training projects in
cognitive therapeutic skills to students and to postgraduate professionals.
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The Albert Ellis Institute, formerly known as the Institute for RationalEmotive Therapy, is a not-for-profit educational organization founded in
1968. Rational Emotive Behavior Therapy (REBT) is a humanistic, actionoriented approach to emotional growth, first articulated by Dr. Albert Ellis in
1955, which emphasizes individuals' capacity for creating their emotions; the
ability to change and overcome the past by focusing on the present; and the
power to choose and implement satisfying alternatives to current behavior
patterns. An estimated 8,000 mental health professionals participate in
Institute training programs and workshops each year.
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offers information and referral services to the general public, the media,
third-party payors, and governmental and nongovernmental agencies.
therapists.
NACBT
offers
cognitive-behavioral
Strategic/Interactional Therapies
Brief Family Therapy Center (BFTC)
P. O. Box 13736
Milwaukee, WI 53213-0736
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abroad have applied to the Foundation for permission to use Dr. Erickson's
name in the titles of their organizations. These institutes provide clinical
services and professional training in major cities around the world.
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Since 1959, the Mental Research Institute of Palo Alto, California, has
been a source of new ideas in the area of interactional/systemic studies,
psychotherapy, and family therapy. It offers a variety of workshops and
trainings
related
to
brief
therapy,
narrative
therapy,
and
strategic/interactional therapies.
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Psychodynamic Therapy
American Psychoanalytic Association (APSA)
309 East 49th Street
New York, NY 10017
Phone: (212) 752-0450
Fax: (212) 593-0571
Web site: http://apsa.org
E-mail: central.office@apsa.org
APSA is a professional organization of psychoanalysts throughout the
United States. The association comprises Affiliate Societies and Training
Institutes in many cities (listed on their Web site at http://apsa.org/organiz/
society.htm) and has about 3,000 individual members. APSA is a Regional
Association of the International Psychoanalytical Association.
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7 Cameo Way
San Francisco, CA 94131
Phone: (415) 282-1661
Web
site:
http://ourworld.compuserve.com/homepages/hstein/homepage.htm
E-mail: HTStein@worldnet.att.net
The Alfred Adler Institute provides distance training, study-analysis,
and case consultation to mental health professionals and students throughout
the world via telephone, E-mail, and the Institute's Web site documents. A
unique mentor-based service offers self-paced programs through customized
training, home study of audio-taped seminars, weekly discussions, and case
consultations by telephone.
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for
the
other
Institutes
can
be
found
at:
http://boulder.earthnet.net/cgjung/)
Family Therapy
American Association for Marriage And Family Therapy (AAMFT)
1133 15th Street, NW, Suite 300
Washington, DC 20005-2710
Phone: (202) 452-0109
Fax: (202) 223-2329
Web site: http://www.aamft.org/
E-mail: Central@aamft.org
AAMFT is the professional association for the field of marriage and
family therapy, representing the professional interests of more than 23,000
marriage and family therapists throughout the United States, Canada, and
abroad. The association facilitates research, theory development, and
education. AAMFT hosts an annual national training conference each fall as
well as a week-long series of continuing education workshops in the summer.
Group Therapy
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5,800 group workers and group work educators. The ASGW Web site
provides a resource base for teachers, students, and practitioners of group
work and includes both organizational information and professional
resources.
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Appendix C
Glossary
Attribution(s): An individual's explanation of why an event occurred. Some researchers believe
that individuals develop attributional styles (i.e., particular ways of explaining
events in their lives that can play a role in the development of emotional problems
and dysfunctional behaviors). The basic attributional dimensions are internal/
external, stable/unstable, and global/specific. For instance, clinically depressed
persons tend to blame themselves for adverse life events (internal), believe that
the causes of negative situations will last indefinitely (stable), and overgeneralize
the causes of discrete occurrences (global). Healthier individuals, on the other
hand, view negative events as due to external forces (fate, luck, environment), as
having isolated meaning (limited only to specific events), and as being transient or
changeable (lasting only a short time).
Authenticity: In existential therapy, this concept refers to the conscious feelings, perceptions,
and thoughts that one expresses and communicates honestly. An individual
achieves authenticity through courage and is thus able to define and discover his
own meaning.
Classical conditioning: According to this theory, an originally neutral stimulus becomes a
conditioned stimulus when paired with an unconditioned stimulus (an event that
elicits a response without any prior learning history) or with a conditioned
stimulus. This is also referred to as stimulus substitution. As applied to substance
abuse, repeated pairings between the emotional, environmental, and subjective
cues associated with use of substances and the actual physiological effects
produced by certain substances lead to the development of a classically
conditioned response. Subsequently, when the substance abuser is in the presence
of such cues, a classically conditioned withdrawal state or craving is elicited.
Cognitive restructuring: The general term applied to the process of changing the client's
thought patterns. Using this process, the therapist identifies distorted "addictive"
thoughts in the client and encourages her to search for more rational ways of
seeing the same event. The client develops and practices these alternative ways of
thinking over the course of cognitive restructuring.
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Contact: A term used in Gestalt therapy that refers to meeting oneself and what is other than
oneself. Without appropriate contact and contact boundaries, there is no real
meeting of the world. Instead, one remains either engulfed by the world or distant
from the world and people. The Gestalt therapist tries to help the client make
contact with the present moment rather than seeking detailed intellectual analysis.
Contingency management: A contingency management approach attempts to change those
environmental contingencies that may influence substance abuse behavior. The
goal is to increase behaviors that are incompatible with use. In particular,
contingencies that are found through a functional analysis to prompt as well as
reinforce substance use are weakened by associating evidence of substance abuse
(e.g., a drug-positive urine screen) with some form of negative consequence or
punishment. Contingencies that prompt and reinforce behaviors that are
incompatible with substance abuse and that promote abstinence are strengthened
by associating them with positive reinforcers.
Core conflictual relationship theme (CCRT): Used in Supportive-Expressive (SE) Therapy, this
concept refers to the way in which the client interacts with others and with herself.
The CCRT is considered to be the center of a client's problems. It develops from
early childhood experiences, but the client is unaware of it and of how it developed.
SE therapy posits that the client will have better control over behavior if she knows
more about what she is doing on an unconscious level.
Core response from others (RO): A term used in SE therapy to explain one way in which the
core conflictual relationship theme is unconsciously developed. The RO represents
an individual's predominant expectations or experiences of others' internal and
external reactions to himself.
Core response of the self (RS): A term used in SE therapy that helps to develop an individual's
core conflictual relationship theme. The RS refers to a more or less coherent
combination of somatic experiences, affects, actions, cognitive style, self-esteem,
and self-representations.
Counterconditioning: A method that uses classical conditioning principles to make behaviors
previously associated with positive outcomes less appealing by more closely
associating them with negative consequences. By repeatedly pairing those cues
that formerly elicited a particular behavior with negative rather than positive
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outcomes, the cues lose their ability to elicit the original classically conditioned
response; instead, they elicit a negative outcome. This is also called an aversive or
counterconditioning treatment approach.
Countertransference: The phenomenon in which the therapist transfers his emotional needs
and feelings onto his client. This can occur to a degree of personal involvement that
seriously harms the therapeutic relationship.
Covert sensitization: A technique used in counterconditioning therapy that pairs negative
consequences with substance-related cues through visual imagery.
Cue exposure: This principle of classical conditioning holds that if a behavior occurs repeatedly
across time but is not reinforced, the strength of both the cue for the behavior and
the behavior itself will diminish, and the behavior will eventually vanish. Using cue
exposure, a client is presented with physical, environmental, social, or emotional
cues associated with past substance abuse (e.g., by accompanying her into an oftenfrequented bar). The client then is prevented from drinking or taking drugs. This
process, over time, leads to decreased reactivity to such cues.
Defense mechanisms: The measures taken by an individual's ego to relieve excessive anxiety.
When the environment causes excessive stress, the client's ego will operate
unconsciously to deny, distort, or falsify reality. Defense mechanisms include
denial, displacement, grandiosity, introjection, isolation, projection, repression,
regression, undoing, and identification with the aggressor.
Deliberate exception: A situation in which a client has intentionally maintained a period of
sobriety or reduced use for any reason. For example, a client who did not use
substances for a month in order to pass a drug test for a new job has made a
deliberate exception to his typical pattern of daily substance use. If he is reminded
that he did this in the past, it will demonstrate that he can do so in the future.
Directive approach: This form of group therapy offers structured goals and therapist-directed
interventions to enable individuals to change in desired ways. It is a contrast to the
process-sensitive approach. The directive approach addresses specific agenda
items in a logical order with greater emphasis on content as the primary source of
effective change.
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Effect expectancies: A set of cognitive expectancies that the client develops concerning
anticipated effects on her feelings and behavior as drinking and drug use are
reinforced by the positive effects of the substance being taken. These represent the
expectation she holds that certain effects will predictably result from drinking or
using specific drugs.
Family sculpting: A technique used in family therapy. The therapist "sculpts" family members in
typical roles and presents significant situations related to substance abuse
patterns. In this process, family members enact a scene to graphically depict the
problem. The physical arrangement of the family members can illustrate emotional
relationships and conflicts within the family. For example, a family may naturally
break up into a triad of the mother, sister, and brother, and a dyad of the father and
another sibling. In that case, the therapist might highlight the fact that the mother
and father communicate through one of their children and never talk to each other
directly.
Functional analysis: A process used in behavioral and cognitive-behavioral therapy that probes
the situations surrounding the client's substance abuse. A functional analysis
examines the relationships among stimuli that trigger use and the consequences
that follow. This can provide important clues regarding the meaning of the
substance use behavior to the client, as well as possible motivators and barriers to
change. In these forms of therapy, this is a first step in providing the client with
tools to manage or avoid situations that trigger substance use. Functional analysis
yields a roadmap of a client's interpersonal, intrapersonal, and environmental
catalysts and reactions to substance use, thereby identifying likely precursors to
substance use.
Insight: A particular kind of self-realization or self-knowledge, usually regarding the connections
of experiences and conflicts in the past with present perceptions and behavior, and
the recognition of feelings or motivations that have been repressed.
Miracle question: A solution-focused interviewing strategy in which the therapist asks the client
the question, "If a miracle happened and your condition were suddenly not a
problem for you, how would your life be different?" This forces the client to
consider a life without substance use and to imagine himself enjoying that life.
Operant learning: Operant learning refers to the process by which behaviors that are reinforced
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increase in frequency. Behaviors that result in positive outcomes or that allow the
client to avoid negative consequences are likely to increase in frequency. Substance
use in the presence of classically conditioned cues is instrumental in reducing or
eliminating the arousal associated with a state of craving, thus serving to reinforce
the substance abuse behavior. That is, the behavior serves a basic rewarding
function for the individual. For example, an alcohol abuser who drinks to feel more
social and less anxious is using substances in an instrumental way. To the extent
that she experiences the effects she seeks, the greater the likelihood she will use
alcohol under similar circumstances in the future.
Process-sensitive approach: This term consists of two, somewhat different, contrasting types of
group psychotherapy. The process-sensitive group approach examines the
unconscious processes of the group as a whole, using these energies to help
individuals see themselves more clearly and therefore open up the opportunity for
change. The first type of process-sensitive approach may be termed the "group-asa-whole" approach and sees healing as an extension of the individuals within the
group as the group comes to terms with a commonly shared anxiety. The second
type of process-sensitive approach uses an interactional group process model. By
attending to the relationships within the group and helping individuals understand
themselves within the relational framework, an interactional group process
provides individuals with significant information about how their behavior affects
others and how they are in turn affected by other members.
Psychodrama: A method of psychotherapy in which clients act out their personal problems by
spontaneously enacting specific roles in dramatic performances performed before
fellow clients.
Random exception: An occasion upon which a client reduces substance use or abstains because
of circumstances that are apparently beyond his control. The client may say, for
example, that he was just "feeling good" and did not feel the urge to use at a
particular time but cannot point to any intentional behaviors on his part that
enabled him to stay sober. In such instances, the therapist can ask the client to try
to predict when such a period of "feeling good" might occur again, which will force
him to begin thinking about the behaviors that may have had an effect on creating
the random exception.
Selfobject: A term used in self psychology that refers to something or someone else that is
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experienced and used as if it were part of one's own self. For example, a child is
dependent on her parent's love and praise in order to develop a sense of self-worth
and self-esteem. In that way, the child internalizes a part of the parent as the
selfobject.
Therapeutic alliance: The relationship between the therapist and client. In all psychodynamic
therapies, the first goal is to establish a "therapeutic alliance" between therapist
and client, because this association functions as the vehicle through which change
occurs. A therapeutic alliance requires intimate self-disclosure on the part of the
client and an empathic and appropriate response on the part of the therapist. In
brief psychodynamic therapy, this alliance must be established as soon as possible,
and the therapist must be able to establish a trusting relationship with his client in
a short time.
Transference: The process, basic to all psychodynamic therapies, of the client's transference of
salient characteristics of unresolved conflicted relationships with significant others
onto the therapist. For example, a client whose relationship with her father is
deeply conflicted may find herself reacting to the therapist as if he were her father.
An initial goal of brief psychodynamic therapy is to foster transference by building
the therapeutic relationship. Only then can the therapist help the client begin to
understand her reasons for using substances and to consider alternative, more
positive behavior.
Transpersonal awakening: The process of awakening from a lesser to a greater identity in
transpersonal psychotherapy. This form of therapy uses the healing nature of
subjective awareness and intuition in the process of awakening and employs the
therapeutic relationship as a vehicle for this awakening in both client and therapist.
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Appendix D
Health Promotion Workbook
Reprinted with permission from Barry, K.L., and Blow, F.C., 1998.
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Exercise
none
seldom
1-2 days per week
3-5 days per week
6-7 days per week
not applicable
fewer than 15
minutes
15-30 minutes
more than 30
minutes
Nutrition
no change in weight
gained more than
10 pounds
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Tobacco Use
no
yes
yes, which ones?
cigarettes
chewing
tobacco
pipe
1-9
10-19
20-29
30+
Alcohol Use
1-2 drinks
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3-4 drinks
5-6 drinks
7 or more
Binge drinking within last month (5 or more drinks per
occasion for women; 6 or more drinks per occasion for
men)
none
1-2 binges
6-7 binges
8 or more
no
yes
if yes, which ones?
exercise
nutrition
tobacco use
alcohol use
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Types
Abstainers and
light
drinkers
Moderate
drinkers
At-risk drinkers
Alcoholics
Heavy drinking has led to physical need for alcohol and to other
problems
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Depression
Blackouts
Problems at work or school
Liver problems
Sexual performance problems
Sleep problems
Arrests for driving under the influence of alcohol
Sexually transmitted diseases
Car crashes
High blood pressure
Accidents / injuries
Relationship problems
Increased risk of sexual assault
Financial problems
Stomach pain
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Write down the three most important reasons you chose to cut down or
quit drinking.
1.________________________________________________________
2.________________________________________________________
3.________________________________________________________
Think about the consequences of continuing to drink heavily. Now think
about how your life might improve if you change your drinking habits by
cutting down or quitting. What improvements do you anticipate?
Physical health:
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Mental health:
Family:
Other relationships:
Work/school:
Financial:
Legal:
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The drinks shown below in normal measure contain roughly the same
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amount of pure alcohol. You can think of each one as a standard drink.
Diary Card
KEEP TRACK OF WHAT YOU DRINK OVER THE NEXT 7 DAYS STARTING
DATE ___________________
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Day
Beer
Wine
Liquor
Number
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
WEEK'S TOTAL:
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Criticism
Dinner parties
Children
TV or magazine Ads
Anger
Watching television
Other people drinking
Certain places
After work
Weekends
Arguments
What are some situations that make you want to drink at a risky level?
Please write them down.
1.____________________________________________________________
2.____________________________________________________________
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It is important to figure out how you can make sure you will not go over
drinking limits when you are tempted. Here are examples:
Telephone a friend
Go for a walk
Call on a neighbor
Watch a movie
Read a book
Participate in a sport
Some of these ideas may not work for you, but other methods of dealing
with risky situations may work. Identify ways in which you could cope with
the specific risky situations you listed above.
1. For the first risky situation or feeling, write down different ways of
coping.
2. For the second risky situation or feeling, write down different ways
of coping.
Think about other situations and ways in which you could cope without
using alcohol.
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Visit Summary
We have covered a great deal of information today. Changing one's
behavior, especially drinking patterns, can be a difficult challenge. The
following pointers may help you stick with your new behavior and maintain
the drinking limit agreement, especially during the first few weeks when it is
most difficult.
Remember that you are changing a habit and that it can be hard
work. It becomes easier with time.
Remember
your
drinking
limit
goal:_______________________________________
Read this workbook frequently.
Every time you are tempted to drink above limits and are able to
resist, congratulate yourself because you are breaking an old
habit.
Whenever you feel very uncomfortable, tell yourself that the
feeling will pass.
At the end of each week, think about how many days you have
been abstinent (have consumed no alcohol) or have been a
light or moderate drinker.
Some people have days during which they drink too much. If that
happens to you, DON'T GIVE UP. Just start again the next day.
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Appendix E
Resource Panel
Gregory Barranco
Assistant Vice President
Government Relations
National Council for Community Behavioral Healthcare
Rockville, Maryland
Peggy Clark, M.S.W., M.P.A.
Behavioral Health/Medicaid Managed Care
Health Care Financing Administration
Baltimore, Maryland
Peter J. Cohen, M.D., J.D.
Associate Professor of Law
Georgetown University Law Center
Washington, D.C.
N. Ross Deck
Deputy Director
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Appendix F
Field Reviewers
Henrietta Robin Barnes, M.D.
Assistant Professor of Medicine
Cambridge Health Alliance
Cambridge Family Health
Harvard Medical School
Cambridge, Massachusetts
Jerome R. Barry, M.S., L.M.H.D., C.P.C., C.A.D.A.C.
Director
St. Francis Medical Center
Grand Island, Nebraska
Insoo Kim Berg, Ph.D., M.S.W.
Director
The Brief Family Therapy Center
Brookfield, Wisconsin
JudyAnn Bigby, M.D.
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Medical Director
Community Health Services
Brigham and Women's Hospital
Boston, Massachusetts
Susan B. Blacksher, M.S.W.
Executive Director
California Association of Addiction Recovery Resources
Sacramento, California
Patricia Bradford, L.I.S.W., L.M.F.T., C.T.S.
Clinical Social Worker/Coordinator
WJB Dunn Medical Center
Department of Veterans Affairs
Columbia, South Carolina
Milton Earl Burglass, M.D.
Professor and Theologian
Addiction Medicine
Neuropsychiatric, Family, and Legal Medicine
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Homestead, Florida
Anthony J. Cellucci, Ph.D.
Associate Professor of Psychology
Director, Idaho State University Clinic
Idaho State University
Pocatello, Idaho
Larry Halverson, M.D.
Springfield, Missouri
Thomas J. Harvey, M.S.W.
Senior Vice President for Member Services
The Alliance for Children and Famlies
Milwaukee, Wisconsin
James N. Heckler, M.S., M.B.A., C.A.S.A.C.
Managed Care Liaison
New York State Office of Alcoholism and Substance Abuse
Services
Albany, New York
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Associate Professor
Department of Psychiatry U
niversity of Minnesota
Minneapolis, Minnesota
David K. Yamakawa, Jr.
Attorney at Law
San Francisco, California
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